Claims workbench/CLM-2026-034095

Institutional claim · UB-04 · EDI 837I

CLM-2026-034095

Riverside Imaging Center, Radiology. Service 2026-09-27 at outpatient hospital (POS 22). Received 2026-10-24.

PendedIdentity on hold: CASE-003478

Billed

$1,850.00

2 lines

Allowed

$1,017.50

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jacqueline Black
Member ID: none on golden record
Date of birth: 1988-08-17
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-404085
Relationship: Child

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Riverside Imaging Center
Radiology · taxonomy 2085R0202X
NPI: 7427092680
Network: In network
Rendering NPI: 8391485629 (Pinecrest Diagnostic Imaging)
Location: Mesa, AZ · TIN 33-8428995
Authorisation / referral: PA2025150016 / 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	74177 rev 0350	CT abdomen and pelvis with contrast	—	1	1	$1,474.00	$810.70	—	—	PendedIDQ
2	77067 rev 0403	Screening mammography, bilateral	—	1	2	$376.00	$206.80	—	—	PendedIDQ
Totals						$1,850.00	$1,017.50	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. M25.561 Pain in right knee
3. R51.9 Headache, unspecified

Claim header

Patient account: PA-810477
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-003478; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 27 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-034094, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2025150016 on file for 74177.
Provider network	Pass		In-network provider Riverside Imaging Center (7427092680).
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Imaging Center2026-09-27 09:31
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-10-24 04:44
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

Prior auth letterPA2025150016_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-09-27 to 2026-12-26.
Itemized billitemized_PA-810477.pdf2 pages
Itemised statement totalling $1850.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-003478; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Same member, date of service and procedures as CLM-2026-034094, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-034094	2026-09-27	Pinecrest Diagnostic Imaging	$1,850.00	Pended

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

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity