Claims workbench/CLM-2026-012316
Institutional claim · UB-04 · EDI 837I

CLM-2026-012316

Riverside Community Hospital, Emergency Medicine. Service 2026-04-15 at emergency room (POS 23). Received 2026-04-17.

Pended
Billed
$2,960.00
2 lines
Allowed
$1,628.00
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Eric Cole
Member ID
none on golden record
Date of birth
1992-11-06
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-401369
Relationship
Child, Tempe, AZ

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
199285
rev 0450
Emergency department visit, high severity with threat to life—11$2,203.00$1,211.65——PendedN30
299283
rev 0450
Emergency department visit, moderate severity—11$757.00$416.35——PendedN30
Totals$2,960.00$1,628.00——
Diagnoses (ICD-10-CM)
  • 1. J18.9 Pneumonia, unspecified organismprincipal
  • 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
  • 3. R55 Syncope and collapse
Claim header
Patient account
PA-974253
Frequency code
1 (original)
Accident
Yes
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-026322 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 2 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 Hospital2026-04-15 16:37

    Follow-up for pneumonia, unspecified organism. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-974253.pdf6 pages

    Itemised statement totalling $2960.00 across 2 lines.

  • Er reported_report_PA-974253.pdf2 pages

    Emergency department record: triage acuity 2, chief complaint pneumonia, unspecified organism.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    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