Claims workbench/CLM-2026-008998
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008998

Summit Family Practice, Family Medicine. Service 2026-05-21 at office (POS 11). Received 2026-06-22.

PendedIdentity on hold: CASE-001226
Billed
$247.00
1 line
Allowed
$153.14
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Kevin Austin
Member ID
UHC-73758-62
Date of birth
1995-06-19
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-403726
Relationship
Child, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group N/A
Coverage period
2022-04-01 to present
Deductible
$43.53 of $500.009%
Out-of-pocket maximum
$490.01 of $1,000.0049%
Copays
office $25.00, specialist $50.00, emergency $350.00
Physical therapy visits
13 of 20 used

Provider

Billing and rendering

Billing provider
Summit Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
3071022859
Network
In network
Rendering NPI
5123306495
Location
Minneapolis, MN · TIN 67-3208363
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199203Office visit, new patient, low complexity—11$247.00$153.14——PendedIDQ
Totals$247.00$153.14——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-632588
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-001226; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-05-21: CHOICE-PLUS-PPO (PPO), effective 2022-04-01.
Timely filingPassReceived 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Summit Family Practice (3071022859).
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: Summit Family Practice2026-05-21 14:01

    Follow-up for hyperlipidemia, 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-001226; payment withheld until the identity is confirmed.

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
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