Claims workbench/CLM-2026-031857
Professional claim · CMS-1500 · EDI 837P

CLM-2026-031857

Mesa Internal Medicine Associates, Internal Medicine. Service 2026-02-26 at office (POS 11). Received 2026-04-08.

Pended
Billed
$204.00
2 lines
Allowed
$126.48
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Emily Wallaec
Member ID
none on golden record
Date of birth
2004-10-05
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-413653
Relationship
Self

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Mesa Internal Medicine Associates
Internal Medicine · taxonomy 207R00000X
NPI
1153640218
Network
In network
Rendering NPI
3903769768
Location
Houston, TX · TIN 60-7207391
Authorisation / referral
none / REF976141

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193000Electrocardiogram with interpretation—11$119.00$73.78——PendedN30
280053Comprehensive metabolic panel—11,2$85.00$52.70——PendedN30
Totals$204.00$126.48——
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I48.91 Unspecified atrial fibrillation
Claim header
Patient account
PA-135596
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 identityPassAttached to MBR-024654 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 41 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Mesa Internal Medicine Associates (1153640218).
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: Mesa Internal Medicine Associates2026-02-26 17:33

    Established patient presents with chronic kidney disease, stage 3 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
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0230752026-04-04Canyon GI Associates$319.00Pended

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