Claims workbench/CLM-2026-026717
Institutional claim · UB-04 · Provider portal

CLM-2026-026717

Cornerstone Imaging Center, Radiology. Service 2026-03-03 at outpatient hospital (POS 22). Received 2026-03-10.

Pended
Billed
$3,039.00
2 lines
Allowed
$1,671.45
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Joshua Lawson
Member ID
none on golden record
Date of birth
1965-11-09
Identity
Verified2 records, confidence 0.93
Claim record
CLMCLM-413826
Relationship
Self, Denver, CO

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Cornerstone Imaging Center
Radiology · taxonomy 2085R0202X
NPI
9835477198
Network
In network
Rendering NPI
9835477198
Location
Tampa, FL · TIN 89-9420622
Authorisation / referral
PA2026244941 / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$117.00$64.35——PendedN30
270553
rev 0610
MRI brain with and without contrast—12$2,922.00$1,607.10——PendedN30
Totals$3,039.00$1,671.45——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. R10.9 Unspecified abdominal pain
  • 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
Claim header
Patient account
PA-607459
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-018803 (verified, link confidence 0.93).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026244941 on file for 70553.
Provider networkPassIn-network provider Cornerstone Imaging Center (9835477198).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Cornerstone Imaging Center2026-03-03 17:36

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Prior auth letterPA2026244941_approval.pdf2 pages

    Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-03-03 to 2026-06-01.

  • Itemized billitemized_PA-607459.pdf5 pages

    Itemised statement totalling $3039.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

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

Outcome
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity