Claims workbench/CLM-2026-007936

Professional claim · CMS-1500 · Provider portal

CLM-2026-007936

Unity Primary Care Associates, Family Medicine. Service 2026-09-05 at office (POS 11). Received 2026-09-10.

PendedOut of networkIdentity on hold: CASE-001203

Billed

$172.00

1 line

Allowed

$77.40

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Sara Padilla
Member ID: none on golden record
Date of birth: 1982-02-02
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-410107
Relationship: Self, Glendale, AZ

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-7777
Coverage period: 2024-02-01 to present
Deductible: $15.46 of $3,500.000%
Out-of-pocket maximum: $2,316.17 of $7,000.0033%
Copays: office $30.00, specialist $40.00, emergency $250.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Unity Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 8247321622
Network: Out of network
Rendering NPI: 3581714854
Location: Tempe, AZ · TIN 17-5198361
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	$172.00	$77.40	—	—	PendedIDQ
Totals						$172.00	$77.40	—	—

Diagnoses (ICD-10-CM)

1. E78.5 Hyperlipidemia, unspecifiedprincipal
2. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-279176
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001203; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-09-05: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 5 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: Unity Primary Care Associates2026-09-05 17:49
Patient seen for hyperlipidemia, unspecified. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-09-10 02:24
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-10 08:50
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-279176.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-001203; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-05: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. 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

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity