Claims workbench/CLM-2026-020906
Professional claim · CMS-1500 · Paper

CLM-2026-020906

Riverside GI Associates, Gastroenterology. Service 2026-04-15 at office (POS 11). Received 2026-09-28.

Denied
Billed
$211.00
1 line
Allowed
$130.82
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Julie Simmos
Member ID
none on golden record
Date of birth
1977-12-28
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-403724
Relationship
Self, Tucson, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Riverside GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI
7858029219
Network
In network
Rendering NPI
9434990260
Location
San Diego, CA · TIN 69-3440792
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$211.00$130.82——DeniedCO29
Totals$211.00$130.82——
Diagnoses (ICD-10-CM)
  • 1. R10.13 Epigastric painprincipal
  • 2. K21.9 Gastro-esophageal reflux disease without esophagitis
Claim header
Patient account
PA-715626
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-045232 (provisional, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingFailCO29Received 166 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Riverside GI Associates (7858029219).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Riverside GI Associates2026-04-15 12:20

    Patient seen for epigastric pain.

  • SystemSystem: Claims system2026-09-28 04:46

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim. Timely filing: Received 166 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
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 queueMember identity