Claims workbench/CLM-2026-031042

Professional claim · CMS-1500 · Paper

CLM-2026-031042

Heritage Medical Group, Family Medicine. Service 2026-03-09 at office (POS 11). Received 2026-04-08.

Needs reviewOut of network

Billed

$213.00

2 lines

Allowed

$95.85

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Jonathan Dunn
Member ID: UHC-80735-98
Date of birth: 1997-09-20
Identity: Verified3 records, confidence 1.00
Claim record: CLMCLM-413471
Relationship: Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7784
Coverage period: 2025-05-01 to 2026-05-12
Deductible: $358.15 of $3,500.0010%
Out-of-pocket maximum: $4,991.35 of $14,000.0036%
Copays: office $20.00, specialist $75.00, emergency $350.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 1536032422
Network: Out of network
Rendering NPI: 6551373528
Location: Denver, CO · TIN 49-9592909
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	90471	Immunization administration	59	1	1	$35.00	$15.75	—	—	Review
2	99213	Office visit, established patient, low complexity	59	1	1	$178.00	$80.10	—	—	Review
Totals						$213.00	$95.85	—	—

Diagnoses (ICD-10-CM)

1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
2. E78.5 Hyperlipidemia, unspecified
3. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-145739
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-002847 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-03-09: CHOICE-PLUS-PPO (PPO), effective 2025-05-01, terms 2026-05-12.
Timely filing	Pass		Received 30 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Medical Group2026-03-09 10:55
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-04-08 06:15
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-08 17:38
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Medical recordrecords_PA-145739.pdf11 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005630	2026-07-14	Lakeside Imaging Center	$462.00	Denied

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

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity