Claims workbench/CLM-2026-009887

Institutional claim · UB-04 · Provider portal

CLM-2026-009887

Pinecrest Medical Group, Internal Medicine. Service 2026-09-05 to 2026-09-06 at inpatient hospital (POS 21). Received 2026-09-28.

Pended

Billed

$495.00

2 lines

Allowed

$272.25

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: Kayla Schmidt
Member ID: none on golden record
Date of birth: 1973-12-05
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-426092
Relationship: Self, Columbus, OH

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI: 3001804152
Network: In network
Rendering NPI: 5260148932
Location: Dallas, TX · TIN 55-8186699
Authorisation / referral: none / none

Service lines

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99232 rev 0110	Subsequent hospital care	59	1	1	$161.00	$88.55	—	—	PendedN30
2	99215	Office visit, established patient, high complexity	59	1	1,2	$334.00	$183.70	—	—	PendedN30
Totals						$495.00	$272.25	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. E11.65 Type 2 diabetes mellitus with hyperglycemia

Claim header

Patient account: PA-115347
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: 2026-09-05 to 2026-09-07
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-017103 (verified, link confidence 0.99).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 22 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Pinecrest Medical Group (3001804152).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Pinecrest Medical Group2026-09-06 12:39
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-09-28 01:50
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-28 09:57
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Itemized billitemized_PA-115347.pdf9 pages
Itemised statement totalling $495.00 across 2 lines.
Medical recordrecords_PA-115347.pdf18 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-013183	2026-07-09	Summit Counseling Center	$279.00	Pended
CLM-2026-032436	2026-02-26	Meadow Family Practice	$2,169.00	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: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity