Claims workbench/CLM-2026-021540
Professional claim · CMS-1500 · EDI 837P

CLM-2026-021540

Canyon Primary Care Associates, Family Medicine. Service 2026-03-23 at office (POS 11). Received 2026-04-20.

PendedIdentity on hold: CASE-003645
Billed
$240.00
1 line
Allowed
$148.80
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Julia Dan
Member ID
none on golden record
Date of birth
1978-06-17
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-424690
Relationship
Self, Gilbert, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Canyon Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI
2780458347
Network
In network
Rendering NPI
8749199237
Location
Miami, FL · TIN 49-9122267
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199203Office visit, new patient, low complexity—11$240.00$148.80——PendedIDQ
Totals$240.00$148.80——
Diagnoses (ICD-10-CM)
  • 1. M54.50 Low back pain, unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-815519
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 identityFailIDQMember record is in open steward case CASE-003645; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 28 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon Primary Care Associates (2780458347).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Canyon Primary Care Associates2026-03-23 13:25

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

  • SystemSystem: Claims system2026-04-20 00:07

  • AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-04-20 13:27

    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

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003645; payment withheld until the identity is confirmed. 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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity