Claims workbench/CLM-2026-003944
Professional claim · CMS-1500 · EDI 837P

CLM-2026-003944

Northgate Dermatology Clinic, Dermatology. Service 2026-08-28 at office (POS 11). Received 2026-09-03.

PendedIdentity on hold: CASE-001984
Billed
$582.00
3 lines
Allowed
$360.84
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Sophia Marquez
Member ID
none on golden record
Date of birth
1986-09-01
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-406451
Relationship
Spouse, San Antonio, TX

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Northgate Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI
7707045416
Network
In network
Rendering NPI
7269971363
Location
Mesa, AZ · TIN 98-6879674
Authorisation / referral
none / REF843548

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
117110Destruction of benign lesions, up to 14—11$166.00$102.92——PendedIDQ
211102Tangential skin biopsy, single lesion—11$243.00$150.66——PendedIDQ
399213Office visit, established patient, low complexity—12$173.00$107.26——PendedIDQ
Totals$582.00$360.84——
Diagnoses (ICD-10-CM)
  • 1. L30.9 Dermatitis, unspecifiedprincipal
  • 2. L57.0 Actinic keratosis
Claim header
Patient account
PA-284583
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-001984; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 6 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Northgate Dermatology Clinic (7707045416).
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: Northgate Dermatology Clinic2026-08-28 09:06

    Established patient presents with dermatitis, unspecified; 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-001984; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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