Claims workbench/CLM-2026-005129

Professional claim · CMS-1500 · EDI 837P

CLM-2026-005129

Riverside Family Practice, Family Medicine. Service 2026-06-28 at office (POS 11). Received 2026-08-11.

PendedIdentity on hold: CASE-002837

Billed

$454.00

2 lines

Allowed

$281.48

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Lisa Pena
Member ID: UHC-45922-33
Date of birth: 1956-11-01
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-421337
Relationship: Spouse

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group NULL
Coverage period: 2022-02-01 to present
Deductible: $1,098.28 of $2,500.0044%
Out-of-pocket maximum: $2,630.79 of $10,000.0026%
Copays: office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits: 12 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Family Practice
Family Medicine · taxonomy 207Q00000X
NPI: 1193895335
Network: In network
Rendering NPI: 4100989654
Location: Los Angeles, CA · TIN 66-7778652
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	59	1	1	$243.00	$150.66	—	—	PendedIDQ
2	99203	Office visit, new patient, low complexity	59	1	1,2	$211.00	$130.82	—	—	PendedIDQ
Totals						$454.00	$281.48	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. Z00.00 Encounter for general adult medical examination without abnormal findings

Claim header

Patient account: PA-382256
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

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002837; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-06-28: SELECT-EPO (EPO), effective 2022-02-01.
Timely filing	Pass		Received 44 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 Riverside Family Practice (1193895335).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Family Practice2026-06-28 15:10
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-08-11 01:39
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-11 15:39
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Medical recordrecords_PA-382256.pdf9 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-002837; payment withheld until the identity is confirmed. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity