Claims workbench/CLM-2026-030441
Institutional claim · UB-04 · EDI 837I

CLM-2026-030441

Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-08-02 at outpatient hospital (POS 22). Received 2026-08-29.

Pended
Billed
$2,323.00
1 line
Allowed
$1,277.65
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Alice Hernandez
Member ID
none on golden record
Date of birth
1987-10-06
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-420490
Relationship
Self, Nashville, TN

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
5513308960
Network
In network
Rendering NPI
7789582401
Location
Minneapolis, MN · TIN 38-7701279
Authorisation / referral
PA2026779462 / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
173721
rev 0610
MRI lower extremity joint without contrast—11$2,323.00$1,277.65——PendedN30
Totals$2,323.00$1,277.65——
Diagnoses (ICD-10-CM)
  • 1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
Claim header
Patient account
PA-306881
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

CheckResultCodeDetail
Member identityPassAttached to MBR-004852 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 27 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026779462 on file for 73721.
Provider networkPassIn-network provider Riverside Orthopedic Specialists (5513308960).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Riverside Orthopedic Specialists2026-08-02 14:15

    Patient seen for unilateral primary osteoarthritis, right knee.

Attachments

Documents received with the claim

  • Prior auth letterPA2026779462_approval.pdf2 pages

    Utilisation management approval letter for 73721 (MRI lower extremity joint without contrast), valid 2026-08-02 to 2026-10-31.

  • Itemized billitemized_PA-306881.pdf8 pages

    Itemised statement totalling $2323.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    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