Claims workbench/CLM-2026-031010

Institutional claim · UB-04 · EDI 837I

CLM-2026-031010

Summit Cardiovascular Associates, Cardiology. Service 2026-04-18 at outpatient hospital (POS 22). Received 2026-05-08.

Denied

Billed

$3,193.00

2 lines

Allowed

$1,756.15

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Kyle Rogers
Member ID: UHC-43750-48
Date of birth: 1941-02-15
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-416220
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-2942
Coverage period: 2021-05-01 to 2026-03-22
Deductible: $101.98 of $500.0020%
Out-of-pocket maximum: $302.40 of $2,000.0015%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Summit Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 5138686964
Network: In network
Rendering NPI: 9279004250
Location: Houston, TX · TIN 53-6389420
Authorisation / referral: PA2026220982 / 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	$2,220.00	$1,221.00	—	—	DeniedCO27
2	93306 rev 0480	Echocardiogram, complete	—	1	1	$973.00	$535.15	—	—	DeniedCO27
Totals						$3,193.00	$1,756.15	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
2. I50.9 Heart failure, unspecified

Claim header

Patient account: PA-606907
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-027165 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-04-18 is after coverage terminated on 2026-03-22. Expenses incurred after coverage terminated
Timely filing	Pass		Received 20 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026220982 on file for 70553.
Provider network	Pass		In-network provider Summit Cardiovascular Associates (5138686964).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Summit Cardiovascular Associates2026-04-18 12:53
Patient seen for encounter for general adult medical examination without abnormal findings.
SystemSystem: Claims system2026-05-08 02:23
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-05-08 09:18
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026220982_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-18 to 2026-07-17.
Itemized billitemized_PA-606907.pdf4 pages
Itemised statement totalling $3193.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-04-18 is after coverage terminated on 2026-03-22. 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-2026-008071	2026-04-27	Sunrise Heart Institute	$682.00	Denied
CLM-2026-003515	2026-04-28	Mesa Clinical Laboratories	$62.00	Denied

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity