Claims workbench/CLM-2026-028706

Institutional claim · UB-04 · EDI 837I

CLM-2026-028706

Valley Imaging Center, Radiology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-08-12.

Needs reviewReplacement of CLM-2026-028705

Billed

$1,800.00

2 lines

Allowed

$990.00

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Nancy George
Member ID: UHC-95306-31
Date of birth: 1979-06-04
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-420240
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-5615
Coverage period: 2022-06-01 to present
Deductible: $12.71 of $1,500.001%
Out-of-pocket maximum: $417.43 of $3,000.0014%
Copays: office $40.00, specialist $40.00, emergency $250.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Valley Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 5964910181
Network: In network
Rendering NPI: 5964910181
Location: Austin, TX · TIN 60-0192260
Authorisation / referral: PA2026059323 / REF986468

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	$1,419.00	$780.45	—	—	Review
2	77067 rev 0403	Screening mammography, bilateral	—	1	1	$381.00	$209.55	—	—	Review
Totals						$1,800.00	$990.00	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-504702
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-014018 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-09: CORE-HMO (HMO), effective 2022-06-01.
Timely filing	Pass		Received 34 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-028705; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026059323 on file for 74177.
Provider network	Pass		In-network provider Valley Imaging Center (5964910181).
Medical necessity	Pass		Diagnosis supports the procedures billed.
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: Valley Imaging Center2026-07-09 12:05
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-08-12 05:27
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Prior auth letterPA2026059323_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-07-09 to 2026-10-07.
Itemized billitemized_PA-504702.pdf4 pages
Itemised statement totalling $1800.00 across 2 lines.
Corrected claimcorrected_CLM-2026-028705.pdf1 page
Provider cover letter requesting replacement of CLM-2026-028705.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-028705; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-012163	2026-08-30	Desert Internal Medicine Associates	$149.00	Approved
CLM-2026-028705	2026-07-09	Valley Imaging Center	$1,800.00	Approved
CLM-2026-015563	2026-05-22	Desert Imaging Center	$2,416.00	Approved

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: Replacement

Replacement claim supersedes the original.

Review queue Member identity