Claims workbench/CLM-2026-017479
Professional claim · CMS-1500 · EDI 837P

CLM-2026-017479

Meadow Primary Care Associates, Family Medicine. Service 2026-06-12 at office (POS 11). Received 2026-07-14.

PendedIdentity on hold: CASE-003077
Billed
$355.00
3 lines
Allowed
$220.10
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Wayne James
Member ID
none on golden record
Date of birth
1983-07-16
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-401262
Relationship
Self, Seattle, WA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Meadow Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
9704343703
Network
In network
Rendering NPI
7680985901
Location
Tampa, FL · TIN 74-5049309
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$17.00$10.54——PendedIDQ
290471Immunization administration—11$29.00$17.98——PendedIDQ
399395Preventive visit, 18-39 years—11,2$309.00$191.58——PendedIDQ
Totals$355.00$220.10——
Diagnoses (ICD-10-CM)
  • 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-552541
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-003077; 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 32 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Meadow Primary Care Associates (9704343703).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Meadow Primary Care Associates2026-06-12 16:43

    Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003077; payment withheld until the identity is confirmed. 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