Claims workbench/CLM-2026-029882
Institutional claim · UB-04 · EDI 837I

CLM-2026-029882

Heritage Digestive Health Center, Gastroenterology. Service 2026-02-12 at outpatient hospital (POS 22). Received 2026-02-14.

PendedIdentity on hold: CASE-001065
Billed
$212.00
1 line
Allowed
$116.60
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
IDQ, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Abmer Lopez
Member ID
none on golden record
Date of birth
1974-05-12
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-426731
Relationship
Spouse

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
4437349366
Network
In network
Rendering NPI
4260457252
Location
San Diego, CA · TIN 67-1701611
Authorisation / referral
none / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
188305
rev 0310
Surgical pathology, level IV—11$212.00$116.60——PendedIDQ
Totals$212.00$116.60——
Diagnoses (ICD-10-CM)
  • 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
  • 2. K58.0 Irritable bowel syndrome with diarrhea
Claim header
Patient account
PA-586788
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 identityFailIDQMember record is in open steward case CASE-001065; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 2 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Digestive Health Center (4437349366).
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: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Digestive Health Center2026-02-12 16:18

    Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.

Attachments

Documents received with the claim

  • Itemized billitemized_PA-586788.pdf2 pages

    Itemised statement totalling $212.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-001065; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.

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
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 queueMember identity