Claims workbench/CLM-2026-022941

Professional claim · CMS-1500 · EDI 837P

CLM-2026-022941

Heritage Family Practice, Family Medicine. Service 2025-12-10 at office (POS 11). Received 2026-01-30.

Needs review

Billed

$164.00

2 lines

Allowed

$101.68

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Elijah Ferguson
Member ID: UHC-23904-16
Date of birth: 1965-08-27
Identity: Verified5 records, confidence 0.97
Claim record: CLMCLM-414840
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-4025
Coverage period: 2024-08-01 to present
Deductible: $1,549.92 of $3,500.0044%
Out-of-pocket maximum: $153.28 of $7,000.002%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Family Practice
Family Medicine · taxonomy 207Q00000X
NPI: 3586851693
Network: In network
Rendering NPI: 2025453863
Location: Scottsdale, AZ · TIN 98-1410500
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	$152.00	$94.24	—	—	Review
2	36415	Venipuncture	—	1	1,2	$12.00	$7.44	—	—	Review
Totals						$164.00	$101.68	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. J06.9 Acute upper respiratory infection, unspecified
3. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-884309
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-002766 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2025-12-10: NAVIGATE-HMO (HMO), effective 2024-08-01.
Timely filing	Pass		Received 51 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-022940, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Heritage Family Practice (3586851693).
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Family Practice2025-12-10 12:39
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-01-30 00:10
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-30 14:29
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-022940, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-027523	2026-08-03	Desert Internal Medicine Associates	$243.00	Approved
CLM-2026-022940	2025-12-10	Harbor Family Practice	$164.00	Approved
CLM-2026-011827	2025-12-17	Mesa Internal Medicine Associates	$330.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity