Claims workbench/CLM-2026-033109
Institutional claim · UB-04 · EDI 837I

CLM-2026-033109

Sunrise Skin Care Associates, Dermatology. Service 2026-07-04 at outpatient hospital (POS 22). Received 2026-08-04.

Needs review
Billed
$3,314.00
1 line
Allowed
$1,822.70
if approved
Plan pays
—
Needs review
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Review
CO50
Decided by
Nobody yet
open

Member

Resolved through the identity graph

Member
Logan Lawson
Member ID
UHC-11101-95
Date of birth
1992-11-11
Identity
Verified5 records, confidence 0.99
Claim record
CLMCLM-415618
Relationship
Self, Atlanta, GA

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-9081
Coverage period
2024-01-01 to present
Deductible
$356.01 of $1,000.0036%
Out-of-pocket maximum
$938.27 of $4,000.0023%
Copays
office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits
17 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Skin Care Associates
Dermatology · taxonomy 207N00000X
NPI
1951970627
Network
In network
Rendering NPI
2688006925
Location
Dallas, TX · TIN 80-3585708
Authorisation / referral
PA2026890543 / REF539730

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
170553
rev 0610
MRI brain with and without contrast—11$3,314.00$1,822.70——Review
Totals$3,314.00$1,822.70——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. L30.9 Dermatitis, unspecified
Claim header
Patient account
PA-878167
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-030244 (verified, link confidence 0.99).
EligibilityPassActive on 2026-07-04: CORE-HMO (HMO), effective 2024-01-01.
Timely filingPassReceived 31 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026890543 on file for 70553.
Provider networkPassIn-network provider Sunrise Skin Care Associates (1951970627).
Medical necessityReviewCO5070553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Not medically necessary per payer policy
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Skin Care Associates2026-07-04 10:27

    Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.

  • SystemSystem: Claims system2026-08-04 02:31

    Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.

  • AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-04 09:53

    Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

  • Prior auth letterPA2026890543_approval.pdf2 pages

    Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-04 to 2026-10-02.

  • Itemized billitemized_PA-878167.pdf5 pages

    Itemised statement totalling $3314.00 across 1 line.

  • Medical recordrecords_PA-878167.pdf13 pages

    Clinic notes for a routine annual visit; no symptoms documented.

Claim history

Every event on this claim, sealed in the audit chain

  1. 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

No other claims.

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
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

DeniedCO50scenario: Dx mismatch

Routine diagnosis does not support advanced imaging.

Review queueMember identity