Claims workbench/CLM-2026-011364
Institutional claim · UB-04 · EDI 837I

CLM-2026-011364

Riverside Community Hospital, Emergency Medicine. Service 2025-12-24 at emergency room (POS 23). Received 2026-01-13.

PendedIdentity on hold: CASE-001153
Billed
$481.00
2 lines
Allowed
$264.55
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
Brian Wang
Member ID
none on golden record
Date of birth
—
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-407772
Relationship
Self, Eden Prairie, MN

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI
1928747868
Network
In network
Rendering NPI
1928747868
Location
Mesa, AZ · TIN 30-6800456
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$233.00$128.15——PendedIDQ
271046
rev 0320
Chest X-ray, two views—11$248.00$136.40——PendedIDQ
Totals$481.00$264.55——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
  • 2. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-217775
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-001153; 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 20 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside Community Hospital (1928747868).
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: Riverside Community Hospital2025-12-24 15:50

    Patient seen for pneumonia, unspecified organism.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-217775.pdf8 pages

    Itemised statement totalling $481.00 across 2 lines.

  • Er reported_report_PA-217775.pdf5 pages

    Emergency department record: triage acuity 3, chief complaint pneumonia, unspecified organism.

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-001153; 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