Claims workbench/CLM-2026-007963

Professional claim · CMS-1500 · EDI 837P

CLM-2026-007963

Heritage Primary Care Associates, Family Medicine. Service 2025-12-20 at office (POS 11). Received 2026-02-05.

PendedReplacement of CLM-2026-007962Identity on hold: CASE-000232

Billed

$247.00

3 lines

Allowed

$153.14

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: Larry Burke
Member ID: none on golden record
Date of birth: 1976-07-03
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-418198
Relationship: Spouse

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-1616
Coverage period: 2021-10-01 to present
Deductible: $146.80 of $1,000.0015%
Out-of-pocket maximum: $436.37 of $2,000.0022%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 2218360602
Network: In network
Rendering NPI: 7433628840
Location: Atlanta, GA · TIN 79-7884821
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	36415	Venipuncture	—	1	1	$21.00	$13.02	—	—	PendedIDQ
2	99203	Office visit, new patient, low complexity	—	1	1,2	$185.00	$114.70	—	—	PendedIDQ
3	90471	Immunization administration	—	1	1	$41.00	$25.42	—	—	PendedIDQ
Totals						$247.00	$153.14	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-391597
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000232; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-12-20: UNKNOWN (PPO), effective 2021-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 47 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-007962; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Heritage Primary Care Associates (2218360602).
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: Heritage Primary Care Associates2025-12-20 10:06
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-02-05 00:23
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-007962.pdf1 page
Provider cover letter requesting replacement of CLM-2026-007962.

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-000232; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-20: UNKNOWN (PPO), effective 2021-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. Replacement claim: Frequency code 7 replaces CLM-2026-007962; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-007962	2025-12-20	Heritage Primary Care Associates	$247.00	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: Replacement

Replacement claim supersedes the original.

Review queue Member identity