Claims workbench/CLM-2026-008344
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008344

Evergreen Medical Group, Family Medicine. Service 2026-05-30 at office (POS 11). Received 2026-07-11.

PendedIdentity on hold: CASE-000775
Billed
$16.00
1 line
Allowed
$9.92
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Michelle Smith
Member ID
UHC-47865-40
Date of birth
2003-05-10
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-405061
Relationship
Child

Coverage and accumulators

Found by member ID

Plan
MEDICARE-ADV-A MA group GRP-9198
Coverage period
2023-01-01 to present
Deductible
$1,681.87 of $2,500.0067%
Out-of-pocket maximum
$259.63 of $5,000.005%
Copays
office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Evergreen Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
3925619678
Network
In network
Rendering NPI
5654943708
Location
Phoenix, AZ · TIN 51-3095998
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$16.00$9.92——PendedIDQ
Totals$16.00$9.92——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
Claim header
Patient account
PA-677831
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-000775; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-05-30: MEDICARE-ADV-A (MA), effective 2023-01-01.
Timely filingPassReceived 42 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Medical Group (3925619678).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Evergreen Medical Group2026-05-30 15:46

    Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-000775; payment withheld until the identity is confirmed.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0083452026-05-30Unity Primary Care Associates$16.00Pended

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