Claims workbench/CLM-2026-001174

Institutional claim · UB-04 · EDI 837I

CLM-2026-001174

Riverside GI Associates, Gastroenterology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-02-09.

Approved

Billed

$2,992.00

2 lines

Allowed

$1,645.60

contract rate applied

Plan pays

$841.98

approved

Member owes

$803.62

copay / deductible / 20% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Betty Rojas
Member ID: UHC-59588-79
Date of birth: 1976-12-27
Identity: Verified6 records, confidence 0.98
Claim record: CLMCLM-411318
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-2268
Coverage period: 2023-10-01 to present
Deductible: $906.88 of $1,500.0060%
Out-of-pocket maximum: $2,892.15 of $6,000.0048%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 17 of 20 used

Provider

Billing and rendering

Billing provider: Riverside GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7858029219
Network: In network
Rendering NPI: 4508964580
Location: San Diego, CA · TIN 69-3440792
Authorisation / referral: PA2026385857 / REF728075

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	45378 rev 0750	Colonoscopy, diagnostic	—	1	1	$1,627.00	$894.85	$653.47	$241.38	Paid
2	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	2	$1,365.00	$750.75	$150.15	$600.60	Paid
Totals						$2,992.00	$1,645.60	$803.62	$841.98

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
2. K21.9 Gastro-esophageal reflux disease without esophagitis

Claim header

Patient account: PA-312518
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

Check	Result	Detail
Member identity	Pass	Attached to MBR-010963 (verified, link confidence 0.98).
Eligibility	Pass	Active on 2025-12-30: CORE-HMO (HMO), effective 2023-10-01.
Timely filing	Pass	Received 41 days after service (limit 90).
Duplicate check	Pass	No matching prior claim in the duplicate window.
Prior authorisation	Pass	Authorisation PA2026385857 on file for 45378, 43239.
Provider network	Pass	In-network provider Riverside GI Associates (7858029219).
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. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside GI Associates2025-12-30 16:20
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2026385857_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2025-12-30 to 2026-03-30.
Itemized billitemized_PA-312518.pdf2 pages
Itemised statement totalling $2992.00 across 2 lines.

Explanation of benefits

What the member will see

Amount billed

$2,992.00

Plan discount

$1,346.40

contracted rate

Plan paid

$841.98

You may owe

$803.62

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-21 13:43
Clean claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-002248	2026-09-09	Northgate Internal Medicine Associates	$474.00	Approved
CLM-2026-030442	2026-05-28	Unity Primary Care Associates	$260.00	Approved
CLM-2026-011205	2026-01-10	Canyon Internal Medicine Associates	$242.00	Denied
CLM-2026-025926	2026-02-04	Desert Medical Group	$251.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved 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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity