Claims workbench/CLM-2026-016957
Professional claim · CMS-1500 · EDI 837P

CLM-2026-016957

Evergreen Family Practice, Family Medicine. Service 2026-07-08 at office (POS 11). Received 2026-07-17.

DeniedIdentity on hold: CASE-000764
Billed
$25.00
1 line
Allowed
$15.50
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Jose Bradley
Member ID
none on golden record
Date of birth
2004-11-02
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-427621
Relationship
Spouse

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Evergreen Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
5857456904
Network
In network
Rendering NPI
5669825882
Location
Austin, TX · TIN 44-5200426
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
190471Immunization administration—11$25.00$15.50——DeniedCO18
Totals$25.00$15.50——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
  • 2. J06.9 Acute upper respiratory infection, unspecified
  • 3. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-885741
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-000764; 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 9 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-016956: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Evergreen Family Practice (5857456904).
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: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Evergreen Family Practice2026-07-08 18:46

    Patient seen for hyperlipidemia, unspecified.

  • SystemSystem: Claims system2026-07-17 04:02

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-000764; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-016956: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0169562026-07-08Evergreen Family Practice$25.00Pended

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity