Claims workbench/CLM-2026-031133

Professional claim · CMS-1500 · EDI 837P

CLM-2026-031133

Riverside Family Practice, Family Medicine. Service 2026-08-30 at office (POS 11). Received 2026-10-28.

Needs reviewReplacement of CLM-2026-031132

Billed

$519.00

2 lines

Allowed

$321.78

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Diana Spencer
Member ID: UHC-15396-79
Date of birth: 1942-08-19
Identity: Verified6 records, confidence 1.00
Claim record: CLMCLM-422213
Relationship: Self, Denver, CO

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-5366
Coverage period: 2024-10-01 to present
Deductible: $387.60 of $2,500.0016%
Out-of-pocket maximum: $1,755.96 of $5,000.0035%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Family Practice
Family Medicine · taxonomy 207Q00000X
NPI: 1193895335
Network: In network
Rendering NPI: 5151762254
Location: Los Angeles, CA · TIN 66-7778652
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	99203	Office visit, new patient, low complexity	—	1	1	$232.00	$143.84	—	—	Review
2	99214	Office visit, established patient, moderate complexity	—	1	1	$287.00	$177.94	—	—	Review
Totals						$519.00	$321.78	—	—

Diagnoses (ICD-10-CM)

1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
2. I10 Essential (primary) hypertension
3. M54.50 Low back pain, unspecified

Claim header

Patient account: PA-913075
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-009491 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-08-30: CHOICE-PLUS-PPO (PPO), effective 2024-10-01.
Timely filing	Pass		Received 59 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-031132; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Riverside Family Practice (1193895335).
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 2026-10-21 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: Riverside Family Practice2026-08-30 10:31
Patient seen for type 2 diabetes mellitus without complications. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-10-28 01:24
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-28 17:19
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-031132.pdf1 page
Provider cover letter requesting replacement of CLM-2026-031132.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-031132; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-031132	2026-08-30	Riverside Family Practice	$519.00	Approved
CLM-2026-008592	2026-04-19	Riverside Primary Care Associates	$333.00	Needs review

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity