Claims workbench/CLM-2026-022353

Professional claim · CMS-1500 · EDI 837P

CLM-2026-022353

Lakeside Reference Lab, Clinical Laboratory. Service 2025-12-16 at independent laboratory (POS 81). Received 2026-01-08.

PendedIdentity on hold: CASE-000757

Billed

$110.00

2 lines

Allowed

$68.20

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Aisha Fowler
Member ID: none on golden record
Date of birth: 1946-04-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-404282
Relationship: Self, Nashville, TN

Coverage and accumulators

Found by name and date of birth

Plan: OPTIONS-PPO PPO group GRP-8909
Coverage period: 2021-10-01 to present
Deductible: $559.53 of $2,500.0022%
Out-of-pocket maximum: $430.43 of $10,000.004%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Reference Lab
Clinical Laboratory · taxonomy 291U00000X
NPI: 8593662793
Network: In network
Rendering NPI: 8593662793
Location: Austin, TX · TIN 19-8347023
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	80053	Comprehensive metabolic panel	59	1	1	$54.00	$33.48	—	—	PendedIDQ
2	85025	Complete blood count with differential	59	1	1	$56.00	$34.72	—	—	PendedIDQ
Totals						$110.00	$68.20	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. E78.5 Hyperlipidemia, unspecified

Claim header

Patient account: PA-354991
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

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-000757; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-12-16: OPTIONS-PPO (PPO), effective 2021-10-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 23 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Lakeside Reference Lab (8593662793).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Lakeside Reference Lab2025-12-16 14:15
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-01-08 04:24
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-08 14:51
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Medical recordrecords_PA-354991.pdf4 pages
Operative note describes a single procedure at one site; no separate session.

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-000757; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-16: OPTIONS-PPO (PPO), effective 2021-10-01. Coverage found by name and date of birth because the claim carried no usable member ID. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

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

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity