Claims workbench/CLM-2026-031074
Professional claim · CMS-1500 · EDI 837P

CLM-2026-031074

Lakeside Heart Institute, Cardiology. Service 2026-03-12 at office (POS 11). Received 2026-03-28.

PendedIdentity on hold: CASE-002022
Billed
$222.00
1 line
Allowed
$137.64
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Joyce Hanson
Member ID
UHC-56625-20
Date of birth
1944-01-14
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-416244
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
NULL PPO group NULL
Coverage period
2024-02-01 to present
Deductible
$1,623.09 of $2,500.0065%
Out-of-pocket maximum
$517.75 of $10,000.005%
Copays
office $20.00, specialist $40.00, emergency $250.00
Physical therapy visits
13 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Heart Institute
Cardiology · taxonomy 207RC0000X
NPI
8827628438
Network
In network
Rendering NPI
6280625461
Location
Houston, TX · TIN 99-8948998
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$222.00$137.64——PendedIDQ
Totals$222.00$137.64——
Diagnoses (ICD-10-CM)
  • 1. I50.9 Heart failure, unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-248256
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityFailIDQMember record is in open steward case CASE-002022; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-03-12: NULL (PPO), effective 2024-02-01.
Timely filingPassReceived 16 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Heart Institute (8827628438).
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Lakeside Heart Institute2026-03-12 17:48

    Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-22 12:44
    Member identity: Member record is in open steward case CASE-002022; payment withheld until the identity is confirmed.

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