Claims workbench/CLM-2026-022928
Professional claim · CMS-1500 · EDI 837P

CLM-2026-022928

Sunrise Medical Group, Family Medicine. Service 2025-12-11 at office (POS 11). Received 2026-01-06.

PendedIdentity on hold: CASE-000514
Billed
$259.00
2 lines
Allowed
$160.58
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Tony Taylor
Member ID
none on golden record
Date of birth
1940-06-11
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-429903
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Sunrise Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
7750705916
Network
In network
Rendering NPI
2062009677
Location
Tampa, FL · TIN 44-4657025
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$236.00$146.32——PendedIDQ
236415Venipuncture2511,2$23.00$14.26——PendedIDQ
Totals$259.00$160.58——
Diagnoses (ICD-10-CM)
  • 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-578434
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-000514; 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 26 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Sunrise Medical Group (7750705916).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Sunrise Medical Group2025-12-11 15:27

    Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-000514; 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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity