Claims workbench/CLM-2026-010416
Professional claim · CMS-1500 · EDI 837P

CLM-2026-010416

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-10-05 at office (POS 11). Received 2026-10-12.

PendedIdentity on hold: CASE-002068
Billed
$160.00
1 line
Allowed
$99.20
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Katleen Tran
Member ID
none on golden record
Date of birth
1975-04-20
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-421796
Relationship
Spouse

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI
6545828207
Network
In network
Rendering NPI
1507418378
Location
Miami, FL · TIN 98-4961021
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$160.00$99.20——PendedIDQ
Totals$160.00$99.20——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
  • 2. M17.11 Unilateral primary osteoarthritis, right knee
Claim header
Patient account
PA-247882
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 identityFailIDQMember record is in open steward case CASE-002068; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Northgate Orthopedic Specialists (6545828207).
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: Northgate Orthopedic Specialists2026-10-05 13:54

    Established patient presents with low back pain, unspecified; 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: Member record is in open steward case CASE-002068; payment withheld until the identity is confirmed. 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 queueMember identity