CLM-1003Olivia MartinezDeniedSLA High88% AI
Blue Cross Blue Shield · Commercial · Assigned to Robert Hayes · Updated 2026-04-22
Patient Name
Olivia Martinez
Patient ID
PT-10044
Claim ID
CLM-1003
Visit ID
26001
Payer
Blue Cross Blue Shield
Payer ID
P00288
Carrier Plan
ZipCarPl
Line of Business
Commercial
Provider
Dr. Anil Verma
Provider NPI
1122334455
Billing Group
BILL5
Date of Service
2026-03-12
Charge Posted
2026-03-13
Charge Amount
$850.00
Paid Amount
$0.00
Adjusted Amount
$6.00
Insurance Balance
$828.00
Patient Balance
$22.00
Primary Payer
Blue Cross Blue Shield
Secondary Payer
N/A
Tertiary Payer
N/A
Crossover
No
Assigned To
Robert Hayes
SLA Target
24h
SLA Elapsed
48h
SLA Risk
High
AI Adjudication Recommendation
Appeal / Request Documentation
88%
Appeal / Request Documentation. Based on payer Blue Cross Blue Shield, reason codes, and historical patterns, recommended action with 88% confidence.
Evidence: reason codes CO197; payer history; matched 835 rule.
Risk flags: none
Suggested next action: Appeal / Request Documentation