Claims workbench/CLM-2026-019222
Institutional claim · UB-04 · EDI 837I

CLM-2026-019222

Harbor Regional Medical Center, Emergency Medicine. Service 2026-01-30 at emergency room (POS 23). Received 2026-02-04.

Pended
Billed
$206.00
1 line
Allowed
$113.30
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Ruth Salazar
Member ID
none on golden record
Date of birth
1940-11-24
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-415196
Relationship
Self, Houston, TX

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Harbor Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI
9303939968
Network
In network
Rendering NPI
9303939968
Location
Tempe, AZ · TIN 60-9523328
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
196374
rev 0260
IV push, single drug—11$206.00$113.30——PendedN30
Totals$206.00$113.30——
Diagnoses (ICD-10-CM)
  • 1. R10.9 Unspecified abdominal painprincipal
  • 2. R55 Syncope and collapse
  • 3. R07.9 Chest pain, unspecified
Claim header
Patient account
PA-297660
Frequency code
1 (original)
Accident
Yes
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-010353 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 5 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Regional Medical Center (9303939968).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Harbor Regional Medical Center2026-01-30 17:02

    Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-297660.pdf2 pages

    Itemised statement totalling $206.00 across 1 line.

  • Er reported_report_PA-297660.pdf5 pages

    Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

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