Claims workbench/CLM-2026-033277
Professional claim · CMS-1500 · EDI 837P

CLM-2026-033277

Heritage Digestive Health Center, Gastroenterology. Service 2026-01-31 at office (POS 11). Received 2026-02-07.

Pended
Billed
$296.00
1 line
Allowed
$183.52
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Steven Salazar
Member ID
none on golden record
Date of birth
1950-05-26
Identity
Verified4 records, confidence 1.00
Claim record
CLMCLM-405909
Relationship
Child, Fresno, CA

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
4437349366
Network
In network
Rendering NPI
2529165781
Location
San Diego, CA · TIN 67-1701611
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$296.00$183.52——PendedN30
Totals$296.00$183.52——
Diagnoses (ICD-10-CM)
  • 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
  • 2. K58.0 Irritable bowel syndrome with diarrhea
Claim header
Patient account
PA-669353
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-011094 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 7 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Heritage Digestive Health Center (4437349366).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Heritage Digestive Health Center2026-01-31 11:13

    Established patient presents with gastro-esophageal reflux disease without esophagitis; 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 enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0012742026-01-26Evergreen Family Practice$180.00Pended
CLM-2026-0332782026-01-31Heritage Digestive Health Center$296.00Denied

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