Claims workbench/CLM-2026-005006
Professional claim · CMS-1500 · EDI 837P

CLM-2026-005006

Pinecrest Primary Care Associates, Family Medicine. Service 2026-05-08 at office (POS 11). Received 2026-06-05.

Denied
Billed
$19.00
1 line
Allowed
$11.78
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Jennifer Aguilar
Member ID
none on golden record
Date of birth
1942-11-23
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-423279
Relationship
Spouse, Los Angeles, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Pinecrest Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
6406754658
Network
In network
Rendering NPI
6074822787
Location
Tempe, AZ · TIN 31-0675839
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$19.00$11.78——DeniedCO18
Totals$19.00$11.78——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-703779
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-032596 (verified, link confidence 0.99).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 28 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-005005: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Primary Care Associates (6406754658).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Primary Care Associates2026-05-08 09:40

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-06-05 01:16

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

  • AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-05 12:35

    Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-005005: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0050052026-05-08Pinecrest Primary Care Associates$19.00Pended

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity