Claims workbench/CLM-2026-009912
Professional claim · CMS-1500 · Paper

CLM-2026-009912

Sunrise Medical Group, Family Medicine. Service 2026-05-10 at office (POS 11). Received 2026-06-19.

Pended
Billed
$304.00
3 lines
Allowed
$188.48
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
Chris Hamilton
Member ID
none on golden record
Date of birth
1984-10-03
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-413138
Relationship
Spouse, Seattle, WA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Sunrise Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
7750705916
Network
In network
Rendering NPI
1605809890
Location
Tampa, FL · TIN 44-4657025
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$236.00$146.32——PendedN30
290471Immunization administration—12$44.00$27.28——PendedN30
336415Venipuncture—11$24.00$14.88——PendedN30
Totals$304.00$188.48——
Diagnoses (ICD-10-CM)
  • 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
  • 2. Z00.00 Encounter for general adult medical examination without abnormal findings
Claim header
Patient account
PA-118484
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-035515 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 40 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Medical Group (7750705916).
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: Sunrise Medical Group2026-05-10 18:03

    Established patient presents with type 2 diabetes mellitus without complications; 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
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0099132026-05-10Sunrise Medical Group$304.00Denied
CLM-2026-0186092026-05-12Lakeside Endocrine Associates$431.00Pended

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