Claims workbench/CLM-2026-018037
Professional claim · CMS-1500 · EDI 837P

CLM-2026-018037

Unity Medical Group, Internal Medicine. Service 2026-06-06 at office (POS 11). Received 2026-06-20.

PendedIdentity on hold: CASE-000505
Billed
$390.00
1 line
Allowed
$241.80
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Janice Willis
Member ID
UHC-62619-37
Date of birth
1943-09-05
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-429631
Relationship
Spouse, Orlando, FL

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-8664
Coverage period
2025-05-01 to present
Deductible
$289.29 of $500.0058%
Out-of-pocket maximum
$96.35 of $1,500.006%
Copays
office $25.00, specialist $75.00, emergency $150.00
Physical therapy visits
5 of 20 used

Provider

Billing and rendering

Billing provider
Unity Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
1355996814
Network
In network
Rendering NPI
6583737419
Location
Mesa, AZ · TIN 43-9161942
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199215Office visit, established patient, high complexity—11$390.00$241.80——PendedIDQ
Totals$390.00$241.80——
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
Claim header
Patient account
PA-378354
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

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-000505; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-06-06: NULL (PPO), effective 2025-05-01.
Timely filingPassReceived 14 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Unity Medical Group (1355996814).
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: Unity Medical Group2026-06-06 09:54

    Established patient presents with essential (primary) hypertension; 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-000505; payment withheld until the identity is confirmed.

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