Claims workbench/CLM-2026-006483

Institutional claim · UB-04 · EDI 837I

CLM-2026-006483

Summit Heart Institute, Cardiology. Service 2026-09-24 at outpatient hospital (POS 22). Received 2026-10-15.

Pended

Billed

$583.00

1 line

Allowed

$320.65

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: John Cox
Member ID: none on golden record
Date of birth: —
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-432107
Relationship: Self, Houston, TX

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Summit Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 1318552993
Network: In network
Rendering NPI: 4844143188
Location: Tampa, FL · TIN 24-2775289
Authorisation / referral: none / REF492094

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	93015	Cardiovascular stress test	—	1	1	$583.00	$320.65	—	—	PendedN30
Totals						$583.00	$320.65	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina

Claim header

Patient account: PA-732521
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-046546 (provisional, link confidence 1.00).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 21 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 Summit Heart Institute (1318552993).
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: Summit Heart Institute2026-09-24 18:44
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-10-15 06:22

Attachments

Documents received with the claim

Itemized billitemized_PA-732521.pdf5 pages
Itemised statement totalling $583.00 across 1 line.

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.

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity