Claims workbench/CLM-2026-011498

Professional claim · CMS-1500 · Paper

CLM-2026-011498

Northgate Orthopedic Specialists, Orthopedic Surgery. Service 2026-04-11 at office (POS 11). Received 2026-05-28.

PendedReplacement of CLM-2026-011497Identity on hold: CASE-000197

Billed

$452.00

2 lines

Allowed

$280.24

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Ashley Gordon
Member ID: none on golden record
Date of birth: 1943-03-21
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-432022
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-1685
Coverage period: 2022-06-01 to present
Deductible: $420.78 of $500.0084%
Out-of-pocket maximum: $306.60 of $1,000.0031%
Copays: office $20.00, specialist $40.00, emergency $350.00
Physical therapy visits: 12 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Orthopedic Specialists
Orthopedic Surgery · taxonomy 207X00000X
NPI: 7225530493
Network: In network
Rendering NPI: 5827451159
Location: Charlotte, NC · TIN 40-3118368
Authorisation / referral: none / none

Service lines

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

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99213	Office visit, established patient, low complexity	—	1	1	$196.00	$121.52	—	—	PendedIDQ
2	20610	Joint injection, major joint	—	1	1,2	$256.00	$158.72	—	—	PendedIDQ
Totals						$452.00	$280.24	—	—

Diagnoses (ICD-10-CM)

1. M25.561 Pain in right kneeprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-300900
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000197; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-04-11: - (PPO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 47 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-011497; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Northgate Orthopedic Specialists (7225530493).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within 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 Specialists2026-04-11 15:51
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-05-28 03:37
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-28 14:30
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-011497.pdf1 page
Provider cover letter requesting replacement of CLM-2026-011497.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000197; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-11: - (PPO), effective 2022-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. Replacement claim: Frequency code 7 replaces CLM-2026-011497; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-011497	2026-04-11	Northgate Orthopedic Specialists	$452.00	Pended

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

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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: Replacement

Replacement claim supersedes the original.

Review queue Member identity