Claims workbench/CLM-2026-031691

Professional claim · CMS-1500 · EDI 837P

CLM-2026-031691

Heritage Medical Group, Family Medicine. Service 2026-05-23 at office (POS 11). Received 2026-05-28.

PendedIdentity on hold: CASE-000770

Billed

$232.00

2 lines

Allowed

$143.84

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Charlotte Gray
Member ID: none on golden record
Date of birth: 1975-04-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-403128
Relationship: Self, Tucson, AZ

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-5090
Coverage period: 2023-12-01 to present
Deductible: $1,230.07 of $2,500.0049%
Out-of-pocket maximum: $2,095.06 of $10,000.0021%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 8291940475
Network: In network
Rendering NPI: 9440160635
Location: Mesa, AZ · TIN 22-3534685
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	$198.00	$122.76	—	—	PendedIDQ
2	90471	Immunization administration	—	1	2	$34.00	$21.08	—	—	PendedIDQ
Totals						$232.00	$143.84	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-301330
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-000770; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-05-23: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 5 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	Pass		In-network provider Heritage Medical Group (8291940475).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within 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: Heritage Medical Group2026-05-23 13:41
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-05-28 03:44
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-28 10:41
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-000770; payment withheld until the identity is confirmed. Eligibility: Active on 2026-05-23: CHOICE-PLUS-PPO (PPO), effective 2023-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. Completeness: Documentation incomplete: “Follow-up for low back pain, unspecified. Plan discussed, medications reconciled. Note dic”.

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

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity