Claims workbench/CLM-2026-000778
Professional claim · CMS-1500 · EDI 837P

CLM-2026-000778

Heritage Orthopedic Specialists, Orthopedic Surgery. Service 2026-01-24 at office (POS 11). Received 2026-01-31.

PendedIdentity on hold: CASE-002209
Billed
$482.00
2 lines
Allowed
$298.84
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Brenda Porter
Member ID
none on golden record
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-406620
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
3819335712
Network
In network
Rendering NPI
6467992452
Location
Tampa, FL · TIN 32-1762387
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$216.00$133.92——PendedIDQ
220610Joint injection, major joint—11$266.00$164.92——PendedIDQ
Totals$482.00$298.84——
Diagnoses (ICD-10-CM)
  • 1. M25.561 Pain in right kneeprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-376480
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002209; 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 filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Orthopedic Specialists (3819335712).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Orthopedic Specialists2026-01-24 13:30

    Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002209; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity