Claims workbench/CLM-2026-007532

Professional claim · CMS-1500 · EDI 837P

CLM-2026-007532

Riverside Orthopedic Specialists, Orthopedic Surgery. Service 2026-06-21 at office (POS 11). Received 2026-06-23.

Pended

Billed

$192.00

1 line

Allowed

$119.04

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

N30

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Jessica Pierce
Member ID: none on golden record
Date of birth: 1960-03-20
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-426184
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Riverside Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 4209374246
Network: In network
Rendering NPI: 4374670360
Location: Miami, FL · TIN 51-8195966
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	99213	Office visit, established patient, low complexity	—	1	1	$192.00	$119.04	—	—	PendedN30
Totals						$192.00	$119.04	—	—

Diagnoses (ICD-10-CM)

1. M17.12 Unilateral primary osteoarthritis, left kneeprincipal
2. M25.561 Pain in right knee

Claim header

Patient account: PA-271677
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-017965 (verified, 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 2 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 Orthopedic Specialists (4209374246).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Orthopedic Specialists2026-06-21 15:09
Established patient presents with unilateral primary osteoarthritis, left knee; 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

Rules enginePended2026-10-22 12:44
Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-010073	2026-03-03	Summit Heart Institute	$3,072.00	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