Claims workbench/CLM-2026-005438
Professional claim · CMS-1500 · EDI 837P

CLM-2026-005438

Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-04-04 at independent laboratory (POS 81). Received 2026-04-06.

PendedIdentity on hold: CASE-002826
Billed
$57.00
1 line
Allowed
$35.34
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Joe Ford
Member ID
none on golden record
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-412575
Relationship
Self, Chandler, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside Clinical Laboratories
Clinical Laboratory · taxonomy 291U00000X
NPI
4514050481
Network
In network
Rendering NPI
4514050481
Location
Tempe, AZ · TIN 12-2226671
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
185025Complete blood count with differential—11$57.00$35.34——PendedIDQ
Totals$57.00$35.34——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-188938
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 identityFailIDQMember record is in open steward case CASE-002826; 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 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Clinical Laboratories (4514050481).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Riverside Clinical Laboratories2026-04-04 13:50

    Established patient presents with essential (primary) hypertension; 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 enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002826; 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