Claims workbench/CLM-2026-019445

Professional claim · CMS-1500 · EDI 837P

CLM-2026-019445

Lakeside Bone and Joint Center, Orthopedic Surgery. Service 2026-06-19 at office (POS 11). Received 2026-09-23.

DeniedIdentity on hold: CASE-000267

Billed

$206.00

1 line

Allowed

$127.72

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Cheryl Banks
Member ID: none on golden record
Date of birth: 1985-09-01
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-430665
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by name and date of birth

Plan: SELECT-EPO EPO group GRP-5213
Coverage period: 2025-05-01 to present
Deductible: $294.33 of $500.0059%
Out-of-pocket maximum: $484.04 of $2,000.0024%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 13 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Bone and Joint Center
Orthopedic Surgery · taxonomy 207X00000X
NPI: 9892398337
Network: In network
Rendering NPI: 9121663758
Location: Nashville, TN · TIN 22-6450141
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	20610	Joint injection, major joint	—	1	1	$206.00	$127.72	—	—	DeniedCO29
Totals						$206.00	$127.72	—	—

Diagnoses (ICD-10-CM)

1. M17.11 Unilateral primary osteoarthritis, right kneeprincipal
2. M17.12 Unilateral primary osteoarthritis, left knee

Claim header

Patient account: PA-559712
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

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-000267; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-19: SELECT-EPO (EPO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Fail	CO29	Received 96 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Lakeside Bone and Joint Center (9892398337).
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Bone and Joint Center2026-06-19 18:10
Patient seen for unilateral primary osteoarthritis, right knee.
SystemSystem: Claims system2026-09-23 01:07
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-23 08:07
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000267; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-19: SELECT-EPO (EPO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 96 days after the last date of service (limit 90).

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

Denied by Claims rules engine; an examiner may still override

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity