Claims workbench/CLM-2026-026316

Professional claim · CMS-1500 · EDI 837P

CLM-2026-026316

Evergreen Medical Group, Family Medicine. Service 2026-10-06 at office (POS 11). Received 2026-10-15.

Needs review

Billed

$467.00

2 lines

Allowed

$289.54

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Patrick Jordan
Member ID: UHC-27638-29
Date of birth: 1948-08-20
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-425044
Relationship: Self, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-0897
Coverage period: 2025-08-01 to present
Deductible: $409.68 of $1,000.0041%
Out-of-pocket maximum: $132.68 of $2,000.007%
Copays: office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits: 19 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 3925619678
Network: In network
Rendering NPI: 6380798671
Location: Phoenix, AZ · TIN 51-3095998
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	$189.00	$117.18	—	—	Review
2	99395	Preventive visit, 18-39 years	—	1	1	$278.00	$172.36	—	—	Review
Totals						$467.00	$289.54	—	—

Diagnoses (ICD-10-CM)

1. E78.5 Hyperlipidemia, unspecifiedprincipal
2. J06.9 Acute upper respiratory infection, unspecified

Claim header

Patient account: PA-800553
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-019112 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-10-06: CORE-HMO (HMO), effective 2025-08-01.
Timely filing	Pass		Received 9 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 Evergreen Medical Group (3925619678).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”. Claim lacks information needed for adjudication
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: Evergreen Medical Group2026-10-06 16:43
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-10-15 01:24
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: R. Patel (Claims Examiner II)2026-10-15 12:21
Reviewed with the member's history on file. Holding for the items listed above.

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
Completeness: Documentation incomplete: “Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled. Note di”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-017132	2026-06-23	Meadow Family Practice	$217.00	Approved
CLM-2026-010230	2026-04-19	Cornerstone Diabetes Center	$281.00	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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity