Claims workbench/CLM-2026-034472
Professional claim · CMS-1500 · EDI 837P

CLM-2026-034472

Harbor Endocrine Associates, Endocrinology. Service 2026-04-18 at office (POS 11). Received 2026-04-21.

PendedIdentity on hold: CASE-001352
Billed
$210.00
1 line
Allowed
$130.20
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
Madison Garcia
Member ID
UHC-32274-67
Date of birth
1984-09-25
Identity
Provisional1 records, confidence 1.00
Claim record
CLMCLM-414843
Relationship
Self

Coverage and accumulators

Found by member ID

Plan
CHOICE-PLUS-PPO PPO group GRP-6818
Coverage period
2021-04-01 to present
Deductible
$396.33 of $1,500.0026%
Out-of-pocket maximum
$238.32 of $3,000.008%
Copays
office $40.00, specialist $50.00, emergency $250.00
Physical therapy visits
1 of 20 used

Provider

Billing and rendering

Billing provider
Harbor Endocrine Associates
Endocrinology · taxonomy 207RE0101X
NPI
8826206194
Network
In network
Rendering NPI
8084492429
Location
Nashville, TN · TIN 64-6622080
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$210.00$130.20——PendedIDQ
Totals$210.00$130.20——
Diagnoses (ICD-10-CM)
  • 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
  • 2. E05.90 Thyrotoxicosis, unspecified
Claim header
Patient account
PA-874924
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-001352; payment withheld until the identity is confirmed.
Member identity under steward review
EligibilityPassActive on 2026-04-18: UNKNOWN (PPO), effective 2021-04-01.
Timely filingPassReceived 3 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Harbor Endocrine Associates (8826206194).
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: Harbor Endocrine Associates2026-04-18 10:03

    Established patient presents with type 2 diabetes mellitus without complications; 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-001352; 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