Claims workbench/CLM-2026-033601
Professional claim · CMS-1500 · EDI 837P

CLM-2026-033601

Lakeside Medical Group, Family Medicine. Service 2026-02-14 at office (POS 11). Received 2026-02-22.

PendedIdentity on hold: CASE-003010
Billed
$219.00
1 line
Allowed
$135.78
if approved
Plan pays
—
Pended
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Pend
IDQ
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Arthur Gilbert
Member ID
UHC-40689-89
Date of birth
1962-09-27
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-407364
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-9826
Coverage period
2021-03-01 to present
Deductible
$291.98 of $500.0058%
Out-of-pocket maximum
$188.20 of $1,000.0019%
Copays
office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits
8 of 20 used

Provider

Billing and rendering

Billing provider
Lakeside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI
6025022396
Network
In network
Rendering NPI
2653113375
Location
Houston, TX · TIN 83-6077797
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199213Office visit, established patient, low complexity—11$219.00$135.78——PendedIDQ
Totals$219.00$135.78——
Diagnoses (ICD-10-CM)
  • 1. E78.5 Hyperlipidemia, unspecifiedprincipal
Claim header
Patient account
PA-718082
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 identityFailIDQMember record is in open steward case CASE-003010; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-02-14: UNKNOWN (PPO), effective 2021-03-01.
Timely filingPassReceived 8 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Lakeside Medical Group (6025022396).
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: Lakeside Medical Group2026-02-14 10:28

    Established patient presents with hyperlipidemia, 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 enginePended2026-10-21 13:43
    Member identity: Member record is in open steward case CASE-003010; 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