Claims workbench/CLM-2026-025909

Institutional claim · UB-04 · EDI 837I

CLM-2026-025909

Lakeside Imaging Center, Radiology. Service 2026-08-31 at outpatient hospital (POS 22). Received 2026-10-06.

Needs review

Billed

$2,184.00

2 lines

Allowed

$1,201.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP, CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Gregory Kennedy
Member ID: UHC-80526-03
Date of birth: 1991-09-21
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-422386
Relationship: Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3592
Coverage period: 2024-10-01 to present
Deductible: $258.22 of $500.0052%
Out-of-pocket maximum: $297.03 of $1,000.0030%
Copays: office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits: 12 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 2856185642
Network: In network
Rendering NPI: 7235030955 (Desert Imaging Center)
Location: Miami, FL · TIN 71-0753822
Authorisation / referral: PA2025099267 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,934.00	$1,063.70	—	—	Review
2	77067 rev 0403	Screening mammography, bilateral	—	1	2	$250.00	$137.50	—	—	Review
Totals						$2,184.00	$1,201.20	—	—

Diagnoses (ICD-10-CM)

1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
2. M25.561 Pain in right knee
3. R51.9 Headache, unspecified

Claim header

Patient account: PA-345183
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-014890 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-31: OPTIONS-PPO (PPO), effective 2024-10-01.
Timely filing	Pass		Received 36 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-025908, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2025099267 on file for 74177.
Provider network	Pass		In-network provider Lakeside Imaging Center (2856185642).
Medical necessity	Review	CO50	74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Imaging Center2026-08-31 13:45
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-10-06 06:14
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-06 16:37
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025099267_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-08-31 to 2026-11-29.
Itemized billitemized_PA-345183.pdf4 pages
Itemised statement totalling $2184.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-025908, billed by a different provider. Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-032638	2026-08-21	Northgate Cardiovascular Associates	$5,773.00	Denied
CLM-2026-025908	2026-08-31	Desert Imaging Center	$2,184.00	Needs review

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity