Claims workbench/CLM-2026-033753

Professional claim · CMS-1500 · EDI 837P

CLM-2026-033753

Lakeside Medical Group, Family Medicine. Service 2025-12-27 at office (POS 11). Received 2026-01-03.

DeniedOut of networkIdentity on hold: CASE-000319

Billed

$262.00

3 lines

Allowed

$117.90

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: James Wilson
Member ID: none on golden record
Date of birth: 1998-04-08
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-420064
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: NAVIGATE-HMO HMO group GRP-5868
Coverage period: 2025-07-01 to present
Deductible: $924.03 of $1,500.0062%
Out-of-pocket maximum: $1,466.48 of $3,000.0049%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Lakeside Medical Group
Family Medicine · taxonomy 207Q00000X
NPI: 4961481189
Network: Out of network
Rendering NPI: 8256451708
Location: Mesa, AZ · TIN 54-1409504
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	36415	Venipuncture	—	1	1	$14.00	$6.30	—	—	DeniedCO204
2	90471	Immunization administration	—	1	1,2	$33.00	$14.85	—	—	DeniedCO204
3	99213	Office visit, established patient, low complexity	—	1	2	$215.00	$96.75	—	—	DeniedCO204
Totals						$262.00	$117.90	—	—

Diagnoses (ICD-10-CM)

1. M54.50 Low back pain, unspecifiedprincipal
2. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-829109
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

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-000319; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2025-12-27: NAVIGATE-HMO (HMO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 7 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	Fail	CO204	Billing provider 4961481189 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Lakeside Medical Group2025-12-27 09:12
Established patient presents with low back pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-01-03 06:37
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-000319; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-27: NAVIGATE-HMO (HMO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 4961481189 is out of network and the HMO plan has no out-of-network benefit.

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

Denied by Claims rules engine; an examiner may still override

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity