Claims workbench/CLM-2026-020825

Professional claim · CMS-1500 · Paper

CLM-2026-020825

Northgate Cardiovascular Associates, Cardiology. Service 2026-01-06 at office (POS 11). Received 2026-07-22.

DeniedIdentity on hold: CASE-002999

Billed

$317.00

1 line

Allowed

$196.54

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Nancy Marshall
Member ID: none on golden record
Date of birth: 1995-12-28
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-415235
Relationship: Child, Houston, TX

Coverage and accumulators

Found by name and date of birth

Plan: CORE-HMO HMO group GRP-9102
Coverage period: 2021-08-01 to present
Deductible: $1,670.50 of $3,500.0048%
Out-of-pocket maximum: $2,616.60 of $7,000.0037%
Copays: office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 5594465275
Network: In network
Rendering NPI: 1778037303
Location: Los Angeles, CA · TIN 22-8335037
Authorisation / referral: none / REF300080

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	$317.00	$196.54	—	—	DeniedCO29
Totals						$317.00	$196.54	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I48.91 Unspecified atrial fibrillation
3. I10 Essential (primary) hypertension

Claim header

Patient account: PA-210060
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-002999; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-01-06: CORE-HMO (HMO), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Fail	CO29	Received 197 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 Northgate Cardiovascular Associates (5594465275).
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Cardiovascular Associates2026-01-06 10:12
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-07-22 06:01
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)2026-07-22 09:36
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 engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-002999; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-06: CORE-HMO (HMO), effective 2021-08-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 197 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