Claims workbench/CLM-2026-002471
Professional claim · CMS-1500 · EDI 837P

CLM-2026-002471

Summit Digestive Health Center, Gastroenterology. Service 2026-07-21 at office (POS 11). Received 2026-08-27.

PendedIdentity on hold: CASE-002858
Billed
$302.00
1 line
Allowed
$187.24
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 30% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Kathryn Austin
Member ID
UHC-56978-49
Date of birth
1955-03-27
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-400028
Relationship
Self, Tampa, FL

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-6987
Coverage period
2021-12-01 to present
Deductible
$292.15 of $500.0058%
Out-of-pocket maximum
$7.30 of $1,000.001%
Copays
office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits
1 of 20 used

Provider

Billing and rendering

Billing provider
Summit Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
1126576986
Network
In network
Rendering NPI
8830154646
Location
Nashville, TN · TIN 32-9600100
Authorisation / referral
none / REF236555

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$302.00$187.24——PendedIDQ
Totals$302.00$187.24——
Diagnoses (ICD-10-CM)
  • 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
  • 2. R10.13 Epigastric pain
Claim header
Patient account
PA-247446
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-002858; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-07-21: CORE-HMO (HMO), effective 2021-12-01.
Timely filingPassReceived 37 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Digestive Health Center (1126576986).
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: Summit Digestive Health Center2026-07-21 15:14

    Established patient presents with encounter for screening for malignant neoplasm of colon; 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-002858; 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