Claims workbench/CLM-2026-001786
Professional claim · CMS-1500 · EDI 837P

CLM-2026-001786

Valley Medical Group, Family Medicine. Service 2026-05-12 at office (POS 11). Received 2026-05-14.

PendedIdentity on hold: CASE-001359
Billed
$308.00
1 line
Allowed
$190.96
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
Albert Kim
Member ID
UHC-21636-30
Date of birth
1988-09-03
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-404124
Relationship
Self, Tucson, AZ

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-2596
Coverage period
2022-02-01 to present
Deductible
$233.43 of $500.0047%
Out-of-pocket maximum
$282.36 of $1,000.0028%
Copays
office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Valley Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
5938488512
Network
In network
Rendering NPI
3689414274
Location
Tempe, AZ · TIN 76-2268417
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$308.00$190.96——PendedIDQ
Totals$308.00$190.96——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. E11.9 Type 2 diabetes mellitus without complications
  • 3. E78.5 Hyperlipidemia, unspecified
Claim header
Patient account
PA-112271
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-001359; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-05-12: - (PPO), effective 2022-02-01.
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Valley Medical Group (5938488512).
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: Valley Medical Group2026-05-12 10:44

    Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.

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-001359; 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