Claims workbench/CLM-2026-025666

Professional claim · CMS-1500 · EDI 837P

CLM-2026-025666

Evergreen Internal Medicine Associates, Internal Medicine. Service 2026-04-14 at office (POS 11). Received 2026-06-10.

PendedIdentity on hold: CASE-002859

Billed

$46.00

1 line

Allowed

$28.52

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Kevin Jordan
Member ID: none on golden record
Date of birth: 1973-02-04
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-419788
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: SELECT-EPO EPO group GRP-1939
Coverage period: 2023-07-01 to present
Deductible: $2,721.31 of $3,500.0078%
Out-of-pocket maximum: $3,180.00 of $7,000.0045%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 14 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI: 8561588111
Network: In network
Rendering NPI: 3846967289
Location: Nashville, TN · TIN 40-5460828
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	80053	Comprehensive metabolic panel	—	1	1	$46.00	$28.52	—	—	PendedIDQ
Totals						$46.00	$28.52	—	—

Diagnoses (ICD-10-CM)

1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
2. J44.9 COPD, unspecified
3. E11.65 Type 2 diabetes mellitus with hyperglycemia

Claim header

Patient account: PA-340644
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002859; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-04-14: SELECT-EPO (EPO), effective 2023-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 57 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-025665, billed by a different provider. Possible duplicate
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Evergreen Internal Medicine Associates (8561588111).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Internal Medicine Associates2026-04-14 11:29
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-06-10 00:02
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-10 08:02
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-002859; payment withheld until the identity is confirmed. Eligibility: Active on 2026-04-14: SELECT-EPO (EPO), effective 2023-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Same member, date of service and procedures as CLM-2026-025665, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-025665	2026-04-14	Meadow Internal Medicine Associates	$46.00	Pended

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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity