Claims workbench/CLM-2026-008054
Institutional claim · UB-04 · EDI 837I

CLM-2026-008054

Harbor Regional Medical Center, Emergency Medicine. Service 2026-09-26 at emergency room (POS 23). Received 2026-10-16.

Pended
Billed
$246.00
1 line
Allowed
$135.30
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
Terry Cooper
Member ID
none on golden record
Date of birth
1960-07-24
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-420012
Relationship
Self, Fresno, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Harbor Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
9303939968
Network
In network
Rendering NPI
9303939968
Location
Tempe, AZ · TIN 60-9523328
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
171046
rev 0320
Chest X-ray, two views—11$246.00$135.30——PendedN30
Totals$246.00$135.30——
Diagnoses (ICD-10-CM)
  • 1. S93.401A Sprain of unspecified ligament of right ankle, initial encounterprincipal
  • 2. R10.9 Unspecified abdominal pain
Claim header
Patient account
PA-856013
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

CheckResultCodeDetail
Member identityPassAttached to MBR-012628 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 20 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Regional Medical Center (9303939968).
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: Harbor Regional Medical Center2026-09-26 13:54

    Patient seen for sprain of unspecified ligament of right ankle, initial encounter.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-856013.pdf3 pages

    Itemised statement totalling $246.00 across 1 line.

  • Er reported_report_PA-856013.pdf5 pages

    Emergency department record: triage acuity 2, chief complaint sprain of unspecified ligament of right ankle, initial encounter.

Claim history

Every event on this claim, sealed in the audit chain

  1. 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

ClaimServiceProviderBilledStatus
CLM-2026-0080552026-09-26Harbor Regional Medical Center$246.00Denied

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