Claims workbench/CLM-2026-005497

Professional claim · CMS-1500 · Paper

CLM-2026-005497

Valley Bone and Joint Center, Orthopedic Surgery. Service 2026-08-28 at office (POS 11). Received 2026-09-12.

PendedOut of network

Billed

$229.00

1 line

Allowed

$103.05

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Carol Munoz
Member ID: none on golden record
Date of birth: 1990-03-20
Identity: Verified2 records, confidence 0.97
Claim record: CLMCLM-400219
Relationship: Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Valley Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 9793653152
Network: Out of network
Rendering NPI: 5093054158
Location: Mesa, AZ · TIN 68-9887889
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	20610	Joint injection, major joint	—	1	1	$229.00	$103.05	—	—	PendedN30
Totals						$229.00	$103.05	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal

Claim header

Patient account: PA-703530
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-043959 (verified, link confidence 0.97).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 15 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Valley Bone and Joint Center2026-08-28 09:09
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-008332	2026-08-17	Meadow GI Associates	$290.00	Pended

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity