Claims workbench/CLM-2026-006489
Institutional claim · UB-04 · EDI 837I

CLM-2026-006489

Pinecrest Heart Institute, Cardiology. Service 2026-05-27 at outpatient hospital (POS 22). Received 2026-07-11.

PendedIdentity on hold: CASE-004220
Billed
$8,734.00
1 line
Allowed
$4,803.70
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Anderson Melissa
Member ID
none on golden record
Date of birth
1947-01-17
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-427328
Relationship
Self, Fresno, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Pinecrest Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
8218526324
Network
In network
Rendering NPI
3054761192
Location
Mesa, AZ · TIN 32-1379406
Authorisation / referral
PA2026499825 / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193458
rev 0481
Cardiac catheterisation, left heart—11$8,734.00$4,803.70——PendedIDQ
Totals$8,734.00$4,803.70——
Diagnoses (ICD-10-CM)
  • 1. I50.9 Heart failure, unspecifiedprincipal
Claim header
Patient account
PA-654260
Frequency code
1 (original)
Accident
No
DRG
287
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-004220; 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 45 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026499825 on file for 93458.
Provider networkPassIn-network provider Pinecrest Heart Institute (8218526324).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Heart Institute2026-05-27 11:20

    Patient seen for heart failure, unspecified.

Attachments

Documents received with the claim

  • Prior auth letterPA2026499825_approval.pdf2 pages

    Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-27 to 2026-08-25.

  • Itemized billitemized_PA-654260.pdf3 pages

    Itemised statement totalling $8734.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-004220; 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