Claims workbench/CLM-2026-023711
Professional claim · CMS-1500 · EDI 837P

CLM-2026-023711

Desert Heart Institute, Cardiology. Service 2026-03-20 at office (POS 11). Received 2026-04-30.

Denied
Billed
$331.00
1 line
Allowed
$205.22
if approved
Plan pays
—
Denied
Member owes
—
no coverage
Rules engine
Deny
CO18
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Maison Valdez
Member ID
none on golden record
Date of birth
1998-11-17
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-408216
Relationship
Self, Gilbert, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Desert Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
5901282678
Network
In network
Rendering NPI
3976236752
Location
Mesa, AZ · TIN 39-5178200
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$331.00$205.22——DeniedCO18
Totals$331.00$205.22——
Diagnoses (ICD-10-CM)
  • 1. I50.9 Heart failure, unspecifiedprincipal
Claim header
Patient account
PA-810443
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-010427 (verified, link confidence 0.99).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 41 days after service (limit 90).
Duplicate checkFailCO18Exact duplicate of CLM-2026-023710: same member, date of service, procedures and billing provider.
Exact duplicate claim or service
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Desert Heart Institute (5901282678).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Desert Heart Institute2026-03-20 14:58

    Patient seen for heart failure, unspecified.

  • SystemSystem: Claims system2026-04-30 00:08

    System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-30 08:41

    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

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-023710: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0237102026-03-20Desert Heart Institute$331.00Pended

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queueMember identity