Claims workbench/CLM-2026-000652
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000652

Sunrise Medical Group, Family Medicine. Service 2025-08-15 at office (POS 11). Received 2026-03-22.

DeniedIdentity on hold: CASE-003501
Billed
$20.00
1 line
Allowed
$12.40
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Santiago Tayllor
Member ID
none on golden record
Date of birth
2007-08-18
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-415383
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Sunrise Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
4611967884
Network
In network
Rendering NPI
2787109927
Location
Miami, FL · TIN 60-6374313
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$20.00$12.40——DeniedCO29
Totals$20.00$12.40——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
Patient account
PA-636496
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003501; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingFailCO29Received 219 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Medical Group (4611967884).
Medical necessityPassDiagnosis supports the procedures billed.
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Medical Group2025-08-15 18:51

    Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-03-22 02:06

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

  • AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-22 10:30

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

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-003501; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Timely filing: Received 219 days after the last date of service (limit 90).

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
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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity