Claims workbench/CLM-2026-025592

Professional claim · CMS-1500 · EDI 837P

CLM-2026-025592

Pinecrest Medical Group, Family Medicine. Service 2026-08-22 at office (POS 11). Received 2026-09-07.

Pended

Billed

$402.00

2 lines

Allowed

$249.24

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Pend

CO16

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-5652
Coverage period: 2023-10-01 to present
Deductible: $869.75 of $1,500.0058%
Out-of-pocket maximum: $752.53 of $4,500.0017%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 2732475423
Network: In network
Rendering NPI: 8709654932
Location: Tempe, AZ · TIN 64-9893800
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	$159.00	$98.58	—	—	PendedCO16
2	99203	Office visit, new patient, low complexity	—	1	1,2	$243.00	$150.66	—	—	PendedCO16
Totals						$402.00	$249.24	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-558474
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	Fail	CO16	Claim record is not attached to a resolved identity. Claim lacks information needed for adjudication
Eligibility	Pass		Active on 2026-08-22: OPTIONS-PPO (PPO), effective 2023-10-01.
Timely filing	Pass		Received 16 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 Pinecrest Medical Group (2732475423).
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. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Medical Group2026-08-22 09:56
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

Rules enginePended2026-10-21 13:43
Member identity: Claim record is not attached to a resolved identity.

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue