Claims workbench/CLM-2026-001458

Professional claim · CMS-1500 · EDI 837P

CLM-2026-001458

Sunrise Heart Institute, Cardiology. Service 2026-06-18 at office (POS 11). Received 2026-07-25.

PendedIdentity on hold: CASE-004243

Billed

$705.00

2 lines

Allowed

$437.10

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Frank Ramireez
Member ID: none on golden record
Date of birth: 1974-09-09
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-403088
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: MEDICARE-ADV-A MA group GRP-0296
Coverage period: 2021-02-01 to present
Deductible: $1,358.44 of $3,500.0039%
Out-of-pocket maximum: $2,758.87 of $14,000.0020%
Copays: office $40.00, specialist $50.00, emergency $250.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 7885317132
Network: In network
Rendering NPI: 3899883276
Location: Mesa, AZ · TIN 11-9149520
Authorisation / referral: none / none

Service lines

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99214	Office visit, established patient, moderate complexity	—	1	1	$309.00	$191.58	—	—	PendedIDQ
2	93224	Holter monitor, 48 hours	—	1	2	$396.00	$245.52	—	—	PendedIDQ
Totals						$705.00	$437.10	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina

Claim header

Patient account: PA-898042
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-004243; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-18: MEDICARE-ADV-A (MA), effective 2021-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 37 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Sunrise Heart Institute (7885317132).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication
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: Sunrise Heart Institute2026-06-18 11:48
Patient seen for chest pain, unspecified. Note dictated; signature pending.
SystemSystem: Claims system2026-07-25 06:58
Rendering provider signature missing on the attached note. Development letter sent to provider.

Attachments

Documents received with the claim

No attachments.

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-004243; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-18: MEDICARE-ADV-A (MA), effective 2021-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”.

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

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity