Claims workbench/CLM-2026-019017

Professional claim · CMS-1500 · EDI 837P

CLM-2026-019017

Heritage Primary Care Associates, Family Medicine. Service 2026-04-24 at office (POS 11). Received 2026-06-17.

PendedIdentity on hold: CASE-001669

Billed

$267.00

2 lines

Allowed

$165.54

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: Dennis Grnt
Member ID: none on golden record
Date of birth: 1934-04-27
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-405713
Relationship: Self, Los Angeles, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Heritage Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 3703132464
Network: In network
Rendering NPI: 4797478342
Location: Tempe, AZ · TIN 64-9033821
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	90471	Immunization administration	—	1	1	$32.00	$19.84	—	—	PendedIDQ
2	99203	Office visit, new patient, low complexity	—	1	1	$235.00	$145.70	—	—	PendedIDQ
Totals						$267.00	$165.54	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. Z00.00 Encounter for general adult medical examination without abnormal findings
3. J06.9 Acute upper respiratory infection, unspecified

Claim header

Patient account: PA-993792
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-001669; 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 54 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-019016, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Heritage Primary Care Associates (3703132464).
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: Heritage Primary Care Associates2026-04-24 18:04
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-06-17 06:51
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-17 16:06
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

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-001669; 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-2026-019016, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019016	2026-04-24	Sunrise Medical Group	$267.00	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