Claims workbench/CLM-2026-018496

Professional claim · CMS-1500 · EDI 837P

CLM-2026-018496

Desert Diabetes Center, Endocrinology. Service 2026-05-27 at office (POS 11). Received 2026-07-10.

PendedReplacement of CLM-2026-018495Identity on hold: CASE-003187

Billed

$292.00

2 lines

Allowed

$181.04

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Philip Reynolds
Member ID: none on golden record
Date of birth: 1954-06-13
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-403069
Relationship: Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Desert Diabetes Center
Endocrinology · taxonomy 207RE0101X
NPI: 4143565768
Network: In network
Rendering NPI: 4943278109
Location: Phoenix, AZ · TIN 51-1868485
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	95251	Continuous glucose monitoring, analysis	—	1	1	$235.00	$145.70	—	—	PendedIDQ
2	83036	Hemoglobin A1c	—	1	1,2	$57.00	$35.34	—	—	PendedIDQ
Totals						$292.00	$181.04	—	—

Diagnoses (ICD-10-CM)

1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
2. E05.90 Thyrotoxicosis, unspecified

Claim header

Patient account: PA-448134
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003187; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 44 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-018495; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Desert Diabetes Center (4143565768).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within 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: Desert Diabetes Center2026-05-27 16:13
Patient seen for type 2 diabetes mellitus with hyperglycemia. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-07-10 00:56
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-018495.pdf1 page
Provider cover letter requesting replacement of CLM-2026-018495.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003187; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Replacement claim: Frequency code 7 replaces CLM-2026-018495; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-018495	2026-05-27	Desert Diabetes Center	$292.00	Pended

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

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.

Examiner rationale *

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: Replacement

Replacement claim supersedes the original.

Review queue Member identity