Claims workbench/CLM-2026-023075
Professional claim · CMS-1500 · EDI 837P

CLM-2026-023075

Canyon GI Associates, Gastroenterology. Service 2026-04-04 at office (POS 11). Received 2026-04-08.

Pended
Billed
$319.00
1 line
Allowed
$197.78
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Emily Wallaec
Member ID
none on golden record
Date of birth
2004-10-05
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-413654
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Canyon GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI
8906815153
Network
In network
Rendering NPI
2066251135
Location
Minneapolis, MN · TIN 78-1003957
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$319.00$197.78——PendedN30
Totals$319.00$197.78——
Diagnoses (ICD-10-CM)
  • 1. R10.13 Epigastric painprincipal
  • 2. Z12.11 Encounter for screening for malignant neoplasm of colon
Claim header
Patient account
PA-845221
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-024654 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 4 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Canyon GI Associates (8906815153).
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: Canyon GI Associates2026-04-04 18:18

    Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.

  • SystemSystem: Claims system2026-04-08 03:05

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-08 13:44

    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

  1. Rules enginePended2026-10-22 12:44
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0318572026-02-26Mesa Internal Medicine Associates$204.00Pended

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity