Claims workbench/CLM-2026-009319
Professional claim · CMS-1500 · EDI 837P

CLM-2026-009319

Riverside Primary Care Associates, Family Medicine. Service 2026-06-06 at office (POS 11). Received 2026-07-13.

Pended
Billed
$262.00
3 lines
Allowed
$162.44
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
CO16, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
6269804525
Network
In network
Rendering NPI
2310025889
Location
Los Angeles, CA · TIN 64-8796526
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190471Immunization administration—11$40.00$24.80——PendedCO16
299213Office visit, established patient, low complexity—11,2$204.00$126.48——PendedCO16
336415Venipuncture2512$18.00$11.16——PendedCO16
Totals$262.00$162.44——
Diagnoses (ICD-10-CM)
  • 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-366397
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 37 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Primary Care Associates (6269804525).
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: Riverside Primary Care Associates2026-06-06 18:37

    Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim.

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 queue