Claims workbench/CLM-2026-015360
Professional claim · CMS-1500 · Provider portal

CLM-2026-015360

Desert Medical Group, Family Medicine. Service 2026-03-11 at office (POS 11). Received 2026-03-20.

Pended
Billed
$200.00
1 line
Allowed
$124.00
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Jason Larson
Member ID
none on golden record
Date of birth
1981-03-24
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-409775
Relationship
Self, Dallas, TX

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Desert Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
6663550666
Network
In network
Rendering NPI
9802046315
Location
Mesa, AZ · TIN 39-6249973
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$200.00$124.00——PendedN30
Totals$200.00$124.00——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
Patient account
PA-312648
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 identityPassAttached to MBR-020887 (provisional, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 9 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Medical Group (6663550666).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessReviewCO16Documentation incomplete: “Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.”.
Claim lacks information needed for adjudication
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: Desert Medical Group2026-03-11 11:48

    Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.

  • SystemSystem: Claims system2026-03-20 01:57

    Rendering provider signature missing on the attached note. Development letter sent to provider.

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
    Eligibility: No coverage segment found for the member ID on this claim. Completeness: Documentation incomplete: “Patient seen for hyperlipidemia, unspecified. Note dictated; signature pending.”.

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queueMember identity