Claims workbench/CLM-2026-001502
Professional claim · CMS-1500 · EDI 837P

CLM-2026-001502

Desert Medical Group, Family Medicine. Service 2026-03-24 at office (POS 11). Received 2026-04-03.

PendedIdentity on hold: CASE-001957
Billed
$448.00
2 lines
Allowed
$277.76
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
Omar Perez
Member ID
UHC-67246-08
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-424385
Relationship
Self, Las Vegas, NV

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-4313
Coverage period
2024-08-01 to present
Deductible
$2,698.09 of $3,500.0077%
Out-of-pocket maximum
$5,180.03 of $10,500.0049%
Copays
office $25.00, specialist $60.00, emergency $150.00
Physical therapy visits
14 of 20 used

Provider

Billing and rendering

Billing provider
Desert Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
6663550666
Network
In network
Rendering NPI
3392665402
Location
Mesa, AZ · TIN 39-6249973
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199395Preventive visit, 18-39 years—11$237.00$146.94——PendedIDQ
299213Office visit, established patient, low complexity—12$211.00$130.82——PendedIDQ
Totals$448.00$277.76——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
Patient account
PA-761362
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-001957; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-03-24: CORE-HMO (HMO), effective 2024-08-01.
Timely filingPassReceived 10 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Medical Group (6663550666).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Desert Medical Group2026-03-24 09:16

    Established patient presents with essential (primary) hypertension; 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 enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-001957; payment withheld until the identity is confirmed.

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