Claims workbench/CLM-2026-011270
Professional claim · CMS-1500 · EDI 837P

CLM-2026-011270

Harbor Reference Lab, Clinical Laboratory. Service 2026-08-15 at independent laboratory (POS 81). Received 2026-08-21.

PendedIdentity on hold: CASE-000114
Billed
$98.00
2 lines
Allowed
$60.76
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
Daniel Grreene
Member ID
none on golden record
Date of birth
2007-02-23
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-420112
Relationship
Spouse

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Harbor Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI
4121885428
Network
In network
Rendering NPI
4121885428
Location
Tempe, AZ · TIN 21-1131562
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180061Lipid panel—11$60.00$37.20——PendedIDQ
287086Urine culture—12$38.00$23.56——PendedIDQ
Totals$98.00$60.76——
Diagnoses (ICD-10-CM)
  • 1. N39.0 Urinary tract infection, site not specifiedprincipal
  • 2. E78.5 Hyperlipidemia, unspecified
Claim header
Patient account
PA-115124
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-000114; 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 6 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Reference Lab (4121885428).
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: Harbor Reference Lab2026-08-15 18:44

    Established patient presents with urinary tract infection, site not specified; 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-000114; 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