Claims workbench/CLM-2026-001993
Professional claim · CMS-1500 · EDI 837P

CLM-2026-001993

Riverside Medical Group, Family Medicine. Service 2026-08-29 at office (POS 11). Received 2026-09-11.

PendedIdentity on hold: CASE-003253
Billed
$142.00
1 line
Allowed
$88.04
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
Julia Nguyen
Member ID
UHC-90442-51
Date of birth
1941-11-07
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-402637
Relationship
Child, Plano, TX

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-1983
Coverage period
2022-08-01 to present
Deductible
$273.90 of $3,500.008%
Out-of-pocket maximum
$2,089.41 of $7,000.0030%
Copays
office $20.00, specialist $60.00, emergency $350.00
Physical therapy visits
9 of 20 used

Provider

Billing and rendering

Billing provider
Riverside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
8250558730
Network
In network
Rendering NPI
4836287217
Location
Nashville, TN · TIN 54-5227365
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$142.00$88.04——PendedIDQ
Totals$142.00$88.04——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. E78.5 Hyperlipidemia, unspecified
Claim header
Patient account
PA-959045
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-003253; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-08-29: SELECT-EPO (EPO), effective 2022-08-01.
Timely filingPassReceived 13 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Medical Group (8250558730).
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: Riverside Medical Group2026-08-29 10:18

    Established patient presents with encounter for general adult medical examination without abnormal findings; 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-003253; 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