Professional claim · CMS-1500 · EDI 837P
CLM-2026-002347
Heritage GI Associates, Gastroenterology. Service 2026-02-27 at office (POS 11). Received 2026-03-10.
Pended
Billed
$255.00
1 line
Allowed
$158.10
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43
Member
Resolved through the identity graph
- Member
- Jeffrey Richardson
- Member ID
- none on golden record
- Date of birth
- 2002-02-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-416372
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Eligibility
No coverage segment found for this member.
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 3011947439
- Location
- Tempe, AZ · TIN 81-8461121
- 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 | $255.00 | $158.10 | — | — | PendedN30 |
| Totals | $255.00 | $158.10 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
Claim header
- Patient account
- PA-322960
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012660 (verified, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 11 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 Heritage GI Associates (8459983820). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Pass | Required documentation present. | |
| 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: Heritage GI Associates2026-02-27 09:23
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018935 | 2026-07-28 | Heritage Family Practice | $255.00 | Pended |
| CLM-2026-001851 | 2026-01-31 | Desert Rehabilitation Center | $337.00 | Pended |
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.