Claims workbench/CLM-2026-022345

Institutional claim · UB-04 · EDI 837I

CLM-2026-022345

Evergreen Medical Group, Internal Medicine. Service 2026-02-12 to 2026-02-13 at inpatient hospital (POS 21). Received 2026-03-09.

PendedReplacement of CLM-2026-022344Out of networkIdentity on hold: CASE-002630

Billed

$196.00

1 line

Allowed

$88.20

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Judy Munoz
Member ID: UHC-90489-10
Date of birth: 1938-12-27
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-430171
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-2601
Coverage period: 2025-02-01 to present
Deductible: $684.26 of $3,500.0020%
Out-of-pocket maximum: $3,464.13 of $10,500.0033%
Copays: office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Medical Group
Internal Medicine · taxonomy 207R00000X
NPI: 4796859906
Network: Out of network
Rendering NPI: 3608534111
Location: Denver, CO · TIN 29-0340886
Authorisation / referral: none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99232 rev 0110	Subsequent hospital care	—	1	1	$196.00	$88.20	—	—	PendedIDQ
Totals						$196.00	$88.20	—	—

Diagnoses (ICD-10-CM)

1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
2. J44.9 COPD, unspecified
3. E11.65 Type 2 diabetes mellitus with hyperglycemia

Claim header

Patient account: PA-890161
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: 2026-02-12 to 2026-02-14
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002630; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-02-12: MEDICARE-ADV-A (MA), effective 2025-02-01.
Timely filing	Pass		Received 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-022344; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Medical Group2026-02-13 10:53
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-03-09 00:47
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Itemized billitemized_PA-890161.pdf2 pages
Itemised statement totalling $196.00 across 1 line.
Corrected claimcorrected_CLM-2026-022344.pdf1 page
Provider cover letter requesting replacement of CLM-2026-022344.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-002630; payment withheld until the identity is confirmed. Replacement claim: Frequency code 7 replaces CLM-2026-022344; the original must be voided when this adjudicates. 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-2026-022344	2026-02-12	Evergreen Medical Group	$196.00	Pended

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity