Claims workbench/CLM-2026-028390

Institutional claim · UB-04 · EDI 837I

CLM-2026-028390

Pinecrest Family Practice, Family Medicine. Service 2026-02-10 at outpatient hospital (POS 22). Received 2026-03-17.

Needs review

Billed

$3,459.00

1 line

Allowed

$1,902.45

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO50

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Stephen Ray
Member ID: UHC-90976-19
Date of birth: 1957-01-19
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-402875
Relationship: Child, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-3048
Coverage period: 2025-08-01 to present
Deductible: $311.13 of $1,500.0021%
Out-of-pocket maximum: $752.63 of $3,000.0025%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Family Practice
Family Medicine · taxonomy 207Q00000X
NPI: 9590925530
Network: In network
Rendering NPI: 4996035604
Location: Denver, CO · TIN 80-5640290
Authorisation / referral: PA2025969088 / 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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$3,459.00	$1,902.45	—	—	Review
Totals						$3,459.00	$1,902.45	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. M54.50 Low back pain, unspecified
3. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-550979
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-020204 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-02-10: NAVIGATE-HMO (HMO), effective 2025-08-01.
Timely filing	Pass		Received 35 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025969088 on file for 70553.
Provider network	Pass		In-network provider Pinecrest Family Practice (9590925530).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; 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: Pinecrest Family Practice2026-02-10 16:24
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
SystemSystem: Claims system2026-03-17 02:31
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.

Attachments

Documents received with the claim

Prior auth letterPA2025969088_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-10 to 2026-05-11.
Itemized billitemized_PA-550979.pdf6 pages
Itemised statement totalling $3459.00 across 1 line.
Medical recordrecords_PA-550979.pdf7 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022956	2026-05-19	Lakeside Bone and Joint Center	$2,315.00	Denied

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: Dx mismatch

Notes document medical necessity.

Review queue Member identity