Claims workbench/CLM-2026-030785

Institutional claim · UB-04 · Provider portal

CLM-2026-030785

Evergreen Diagnostic Imaging, Radiology. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-07-23.

DeniedIdentity on hold: CASE-002715

Billed

$2,386.00

2 lines

Allowed

$1,312.30

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Virginia Hoffman
Member ID: none on golden record
Date of birth: 1947-09-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-406686
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: MEDICARE-ADV-B MA group GRP-2246
Coverage period: 2021-01-01 to present
Deductible: $1,114.37 of $2,500.0045%
Out-of-pocket maximum: $1,716.12 of $5,000.0034%
Copays: office $30.00, specialist $75.00, emergency $250.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Diagnostic Imaging
Radiology · taxonomy 2085R0202X
NPI: 7098075170
Network: In network
Rendering NPI: 7098075170
Location: Atlanta, GA · TIN 75-1814880
Authorisation / referral: none / 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	71046 rev 0320	Chest X-ray, two views	—	1	1	$219.00	$120.45	—	—	DeniedCO197
2	70553 rev 0610	MRI brain with and without contrast	—	1	2	$2,167.00	$1,191.85	—	—	DeniedCO197
Totals						$2,386.00	$1,312.30	—	—

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-924387
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002715; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-07-12: MEDICARE-ADV-B (MA), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 11 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	70553 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Evergreen Diagnostic Imaging (7098075170).
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Diagnostic Imaging2026-07-12 09:56
Patient seen for pain in right knee.
SystemSystem: Claims system2026-07-23 03:32
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-23 17:21
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-924387.pdf4 pages
Itemised statement totalling $2386.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-002715; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-12: MEDICARE-ADV-B (MA), effective 2021-01-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 70553 require precertification; no authorisation number on the 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

Denied by Claims rules engine; an examiner may still override

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity