Claims workbench/CLM-2026-013275
Professional claim · CMS-1500 · EDI 837P

CLM-2026-013275

Heritage Clinical Laboratories, Clinical Laboratory. Service 2026-02-09 at independent laboratory (POS 81). Received 2026-02-11.

PendedIdentity on hold: CASE-002706
Billed
$107.00
2 lines
Allowed
$66.34
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Sara Carpenter
Member ID
none on golden record
Date of birth
1949-10-24
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-420739
Relationship
Self, Columbus, OH

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Clinical Laboratories
Clinical Laboratory · taxonomy 291U00000X
NPI
6061087964
Network
In network
Rendering NPI
6061087964
Location
Scottsdale, AZ · TIN 58-0891898
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$65.00$40.30——PendedIDQ
280061Lipid panel—12$42.00$26.04——PendedIDQ
Totals$107.00$66.34——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-807964
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002706; 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 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Clinical Laboratories (6061087964).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Clinical Laboratories2026-02-09 12:30

    Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002706; 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