Claims workbench/CLM-2026-030405

Professional claim · CMS-1500 · EDI 837P

CLM-2026-030405

Riverside Digestive Health Center, Gastroenterology. Service 2026-07-12 at office (POS 11). Received 2026-08-23.

DeniedIdentity on hold: CASE-003534

Billed

$304.00

1 line

Allowed

$188.48

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Brenda Phillips
Member ID: none on golden record
Date of birth: 1961-06-05
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-429100
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: OPTIONS-PPO PPO group GRP-1910
Coverage period: 2025-06-01 to present
Deductible: $385.92 of $3,500.0011%
Out-of-pocket maximum: $3,380.82 of $7,000.0048%
Copays: office $25.00, specialist $75.00, emergency $250.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 9435046427
Network: In network
Rendering NPI: 4541620322
Location: Atlanta, GA · TIN 82-1240911
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	99214	Office visit, established patient, moderate complexity	—	1	1	$304.00	$188.48	—	—	DeniedCO18
Totals						$304.00	$188.48	—	—

Diagnoses (ICD-10-CM)

1. K58.0 Irritable bowel syndrome with diarrheaprincipal

Claim header

Patient account: PA-437059
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-003534; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 42 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-030404: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Riverside Digestive Health Center (9435046427).
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Digestive Health Center2026-07-12 16:28
Patient seen for irritable bowel syndrome with diarrhea.
SystemSystem: Claims system2026-08-23 02:03
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-23 10:55
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 engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003534; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-12: OPTIONS-PPO (PPO), effective 2025-06-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-030404: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-030404	2026-07-12	Riverside Digestive Health Center	$304.00	Pended

AI recommendation

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

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

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity