Claims workbench/CLM-2026-012820

Professional claim · CMS-1500 · EDI 837P

CLM-2026-012820

Lakeside Behavioral Health, Behavioral Health. Service 2026-05-14 at telehealth (POS 02). Received 2026-06-01.

PendedOut of network

Billed

$498.00

2 lines

Allowed

$224.10

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: Steve Jensen
Member ID: none on golden record
Date of birth: 1981-11-03
Identity: Verified2 records, confidence 0.97
Claim record: CLMCLM-401698
Relationship: Spouse, Minneapolis, MN

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Lakeside Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI: 2763853613
Network: Out of network
Rendering NPI: 6007307914
Location: Austin, TX · TIN 90-0644488
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	99214	Office visit, established patient, moderate complexity	59	1	1	$277.00	$124.65	—	—	PendedN30
2	90834	Psychotherapy, 45 minutes	59	1	1	$221.00	$99.45	—	—	PendedN30
Totals						$498.00	$224.10	—	—

Diagnoses (ICD-10-CM)

1. F41.1 Generalized anxiety disorderprincipal

Claim header

Patient account: PA-970619
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-022454 (verified, link confidence 0.97).
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 18 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Lakeside Behavioral Health2026-05-14 16:22
Established patient presents with generalized anxiety disorder; symptoms reviewed and vitals within expected range. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-06-01 06:35
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-01 09:30
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Medical recordrecords_PA-970619.pdf4 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Eligibility: No coverage segment found for the member ID on this claim. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022515	2026-03-12	Canyon Skin Care Associates	$562.00	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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity