Claims workbench/CLM-2026-018940

Professional claim · CMS-1500 · EDI 837P

CLM-2026-018940

Mesa Internal Medicine Associates, Internal Medicine. Service 2026-03-30 at office (POS 11). Received 2026-05-03.

PendedOut of networkIdentity on hold: CASE-001848

Billed

$540.00

2 lines

Allowed

$243.00

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: Mesa Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI: 7667531934
Network: Out of network
Rendering NPI: 6269054998
Location: Miami, FL · TIN 27-5098805
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	99214	Office visit, established patient, moderate complexity	—	1	1	$235.00	$105.75	—	—	PendedIDQ
2	99215	Office visit, established patient, high complexity	—	1	1,2	$305.00	$137.25	—	—	PendedIDQ
Totals						$540.00	$243.00	—	—

Diagnoses (ICD-10-CM)

1. I48.91 Unspecified atrial fibrillationprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-687253
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001848; 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 34 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-018939, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Mesa Internal Medicine Associates2026-03-30 14:44
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-05-03 02:32
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

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. Duplicate check: Same member, date of service and procedures as CLM-2026-018939, billed by a different provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-018939	2026-03-30	Pinecrest Medical Group	$540.00	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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity