Claims workbench/CLM-2026-016960
Institutional claim · UB-04 · EDI 837I

CLM-2026-016960

Canyon Regional Medical Center, Emergency Medicine. Service 2026-05-17 at emergency room (POS 23). Received 2026-06-22.

Pended
Billed
$824.00
2 lines
Allowed
$453.20
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
John Hamilton
Member ID
none on golden record
Date of birth
1939-02-07
Identity
Verified3 records, confidence 0.88
Claim record
CLMCLM-423900
Relationship
Spouse, Tucson, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Canyon Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
7874072318
Network
In network
Rendering NPI
7874072318
Location
Tampa, FL · TIN 53-7384078
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199283
rev 0450
Emergency department visit, moderate severity—11$626.00$344.30——PendedN30
296374
rev 0260
IV push, single drug—11,2$198.00$108.90——PendedN30
Totals$824.00$453.20——
Diagnoses (ICD-10-CM)
  • 1. R10.9 Unspecified abdominal painprincipal
  • 2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter
Claim header
Patient account
PA-745510
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-023586 (verified, link confidence 0.88).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 36 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon Regional Medical Center (7874072318).
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: Canyon Regional Medical Center2026-05-17 16:21

    Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-745510.pdf7 pages

    Itemised statement totalling $824.00 across 2 lines.

  • Er reported_report_PA-745510.pdf4 pages

    Emergency department record: triage acuity 2, chief complaint unspecified abdominal pain.

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.

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