Claims workbench/CLM-2026-016985

Professional claim · CMS-1500 · EDI 837P

CLM-2026-016985

Evergreen Family Practice, Family Medicine. Service 2025-12-14 at office (POS 11). Received 2026-01-09.

Needs review

Billed

$197.00

1 line

Allowed

$122.14

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: George Medina
Member ID: UHC-11140-35
Date of birth: 1973-04-16
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-401296
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-8090
Coverage period: 2023-12-01 to present
Deductible: $202.29 of $500.0040%
Out-of-pocket maximum: $177.32 of $1,000.0018%
Copays: office $40.00, specialist $60.00, emergency $350.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Family Practice
Family Medicine · taxonomy 207Q00000X
NPI: 9703652849
Network: In network
Rendering NPI: 4603583285
Location: Miami, FL · TIN 83-6828766
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	99203	Office visit, new patient, low complexity	—	1	1	$197.00	$122.14	—	—	Review
Totals						$197.00	$122.14	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-784476
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-002590 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-14: CHOICE-PLUS-PPO (PPO), effective 2023-12-01.
Timely filing	Pass		Received 26 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Evergreen Family Practice (9703652849).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature ”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Family Practice2025-12-14 10:07
Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature pending.
SystemSystem: Claims system2026-01-09 04:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-09 13:39
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Patient seen for acute upper respiratory infection, unspecified. Note dictated; signature ”.
AI recommendationPended2026-10-21 14:15
The claim is pended due to incomplete documentation (CO16). The clinical note is missing the provider's signature, as indicated by the system note [N2]. The development letter has been sent to the provider, and the claim will be held until the signature is provided.
AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 120866a5

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Pendedconfidence 0.95 Validated

CO16 Claim lacks information needed for adjudication

The claim is pended due to incomplete documentation (CO16). The clinical note is missing the provider's signature, as indicated by the system note [N2]. The development letter has been sent to the provider, and the claim will be held until the signature is provided.

Evidence cited: [C][DX][L1][PRV][IDN][COV][R-identity][R-eligibility][R-timely_filing][R-duplicate][R-prior_auth][R-network][R-clinical_edit][R-ncci][R-benefit_limit][R-completeness][N1][N2][N3]

Latency

1,849 ms

Tokens

1,224 in / 201 out

Cost

$0.0016

Input hash b28a6b209c3bef3b… · identifiers withheld from the model: name, dob, member_id

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Pre-filled from the AI recommendation. Change anything before you record 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.

Reason codes *

CO16 Claim lacks information needed for adjudication

Examiner rationale *

314 characters

ExaminerR. Patel (Claims Examiner II)

Will apply: pend

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity