Claims workbench/CLM-2026-021936

Professional claim · CMS-1500 · EDI 837P

CLM-2026-021936

Sunrise Dermatology Clinic, Dermatology. Service 2026-06-02 at office (POS 11). Received 2026-07-03.

DeniedOut of networkIdentity on hold: CASE-000693

Billed

$227.00

1 line

Allowed

$102.15

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Stephen Mason
Member ID: none on golden record
Date of birth: 1947-02-10
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-431383
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-9326
Coverage period: 2025-02-01 to present
Deductible: $43.12 of $1,000.004%
Out-of-pocket maximum: $1,129.55 of $4,000.0028%
Copays: office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Dermatology Clinic
Dermatology · taxonomy 207N00000X
NPI: 2690461902
Network: Out of network
Rendering NPI: 1556115396
Location: Houston, TX · TIN 60-8775890
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	99213	Office visit, established patient, low complexity	—	1	1	$227.00	$102.15	—	—	DeniedCO18
Totals						$227.00	$102.15	—	—

Diagnoses (ICD-10-CM)

1. L30.9 Dermatitis, unspecifiedprincipal

Claim header

Patient account: PA-178852
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 4 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-000693; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-06-02: NULL (PPO), effective 2025-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 31 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-021935: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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: Sunrise Dermatology Clinic2026-06-02 11:32
Patient seen for dermatitis, unspecified.
SystemSystem: Claims system2026-07-03 03:30
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-03 15:03
Member services inquiry logged on this claim; member asked about the status of payment.

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-000693; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-02: NULL (PPO), effective 2025-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-021935: same member, date of service, procedures and billing provider. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-021935	2026-06-02	Sunrise Dermatology Clinic	$227.00	Pended

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity