Claims workbench/CLM-2026-034402
Institutional claim · UB-04 · EDI 837I

CLM-2026-034402

Sunrise Behavioral Health, Behavioral Health. Service 2026-01-10 at outpatient hospital (POS 22). Received 2026-01-18.

Needs review
Billed
$2,109.00
1 line
Allowed
$1,159.95
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
Jack Fisher
Member ID
UHC-01029-95
Date of birth
1998-07-20
Identity
Verified3 records, confidence 0.93
Claim record
CLMCLM-403251
Relationship
Spouse, Charlotte, NC

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group N/A
Coverage period
2021-08-01 to present
Deductible
$1,465.68 of $2,500.0059%
Out-of-pocket maximum
$83.21 of $5,000.002%
Copays
office $40.00, specialist $75.00, emergency $350.00
Physical therapy visits
20 of 20 used

Provider

Billing and rendering

Billing provider
Sunrise Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI
9180644400
Network
In network
Rendering NPI
9478650168
Location
Dallas, TX · TIN 81-8341944
Authorisation / referral
PA2025439543 / none

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$2,109.00$1,159.95——Review
Totals$2,109.00$1,159.95——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. F90.2 ADHD, combined type
Claim header
Patient account
PA-742171
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-005555 (verified, link confidence 0.93).
EligibilityPassActive on 2026-01-10: SELECT-EPO (EPO), effective 2021-08-01.
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2025439543 on file for 70553.
Provider networkPassIn-network provider Sunrise Behavioral Health (9180644400).
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 2026-10-22 12:44 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 Behavioral Health2026-01-10 18:39

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.

  • SystemSystem: Claims system2026-01-18 01:03

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

Attachments

Documents received with the claim

  • Prior auth letterPA2025439543_approval.pdf2 pages

    Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-10 to 2026-04-10.

  • Itemized billitemized_PA-742171.pdf4 pages

    Itemised statement totalling $2109.00 across 1 line.

  • Medical recordrecords_PA-742171.pdf8 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 engineReview2026-10-22 12:44
    Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
  2. AI recommendationDenied2026-10-23 19:19
    The claim for an MRI brain with and without contrast (70553) was billed with a routine examination diagnosis (Z00.00). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms documented, which does not support the medical necessity for advanced imaging. Therefore, the claim is denied for not being medically necessary per payer policy (CO50).
  3. AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 0c0ec75c

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode

Deniedconfidence 0.95 Validated
  • CO50 Not medically necessary per payer policy

The claim for an MRI brain with and without contrast (70553) was billed with a routine examination diagnosis (Z00.00). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms documented, which does not support the medical necessity for advanced imaging. Therefore, the claim is denied for not being medically necessary per payer policy (CO50).

Evidence cited: [C][DX][L1][N1][N2][A1][A3]
Latency
1,668 ms
Tokens
1,400 in / 157 out
Cost
$0.0016
Input hash 6b0c8918f9965761… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record it.
Outcome
Reason codes *
  • CO50 Not medically necessary per payer policy
442 characters
ExaminerR. Patel (Claims Examiner II)
Will apply: deny

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