Claims workbench/CLM-2026-018939
Professional claim · CMS-1500 · EDI 837P

CLM-2026-018939

Pinecrest Medical Group, Internal Medicine. Service 2026-03-30 at office (POS 11). Received 2026-04-25.

PendedIdentity on hold: CASE-001848
Billed
$540.00
2 lines
Allowed
$334.80
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
Janice Rose
Member ID
none on golden record
Date of birth
1987-12-14
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-402566
Relationship
Spouse, Denver, CO

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
8331715671
Network
In network
Rendering NPI
6269054998
Location
Minneapolis, MN · TIN 79-7771425
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$235.00$145.70——PendedIDQ
299215Office visit, established patient, high complexity—11,2$305.00$189.10——PendedIDQ
Totals$540.00$334.80——
Diagnoses (ICD-10-CM)
  • 1. I48.91 Unspecified atrial fibrillationprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-701270
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-001848; 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 26 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Medical Group (8331715671).
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: Pinecrest Medical Group2026-03-30 09:15

    Established patient presents with unspecified atrial fibrillation; 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-001848; 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

ClaimServiceProviderBilledStatus
CLM-2026-0189402026-03-30Mesa Internal Medicine Associates$540.00Pended

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