Claims workbench/CLM-2026-010956
Professional claim · CMS-1500 · EDI 837P

CLM-2026-010956

Harbor Diabetes Center, Endocrinology. Service 2026-02-11 at office (POS 11). Received 2026-02-18.

PendedIdentity on hold: CASE-001918
Billed
$351.00
1 line
Allowed
$217.62
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
Jonathan Alvarado
Member ID
UHC-88343-03
Date of birth
1956-01-03
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-422206
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
NULL PPO group NULL
Coverage period
2022-01-01 to present
Deductible
$26.91 of $500.005%
Out-of-pocket maximum
$387.25 of $1,000.0039%
Copays
office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits
22 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Diabetes Center
Endocrinology · taxonomy 207RE0101X
NPI
7519485602
Network
In network
Rendering NPI
4889594568
Location
Tempe, AZ · TIN 55-9687647
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$351.00$217.62——PendedIDQ
Totals$351.00$217.62——
Diagnoses (ICD-10-CM)
  • 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
  • 2. E05.90 Thyrotoxicosis, unspecified
Claim header
Patient account
PA-599765
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-001918; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-02-11: NULL (PPO), effective 2022-01-01.
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 Harbor Diabetes Center (7519485602).
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: Harbor Diabetes Center2026-02-11 18:37

    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 enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-001918; 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