Claims workbench/CLM-2026-014870

Professional claim · CMS-1500 · EDI 837P

CLM-2026-014870

Valley Reference Lab, Clinical Laboratory. Service 2026-07-01 at independent laboratory (POS 81). Received 2026-08-21.

PendedIdentity on hold: CASE-004151

Billed

$148.00

3 lines

Allowed

$91.76

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: Ralph Rodriguez
Member ID: none on golden record
Date of birth: 1991-08-03
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-431979
Relationship: Spouse, Dallas, TX

Coverage and accumulators

Found by name and date of birth

Plan: CORE-HMO HMO group GRP-3438
Coverage period: 2022-08-01 to present
Deductible: $1,310.82 of $1,500.0087%
Out-of-pocket maximum: $564.31 of $3,000.0019%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Valley Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 8777376848
Network: In network
Rendering NPI: 3818568156 (Mesa Clinical Laboratories)
Location: Minneapolis, MN · TIN 45-5717570
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	80053	Comprehensive metabolic panel	—	1	1	$48.00	$29.76	—	—	PendedIDQ
2	80061	Lipid panel	—	1	1	$55.00	$34.10	—	—	PendedIDQ
3	87086	Urine culture	25	1	2	$45.00	$27.90	—	—	PendedIDQ
Totals						$148.00	$91.76	—	—

Diagnoses (ICD-10-CM)

1. E78.5 Hyperlipidemia, unspecifiedprincipal

Claim header

Patient account: PA-155964
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	Fail	IDQ	Member record is in open steward case CASE-004151; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-07-01: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 51 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-014869, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Valley Reference Lab (8777376848).
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: Valley Reference Lab2026-07-01 14:52
Patient seen for hyperlipidemia, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-08-21 00:43
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

No attachments.

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-004151; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-01: CORE-HMO (HMO), effective 2022-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Same member, date of service and procedures as CLM-2026-014869, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014869	2026-07-01	Mesa Clinical Laboratories	$148.00	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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity