Claims workbench/CLM-2026-002465

Institutional claim · UB-04 · Paper

CLM-2026-002465

Canyon Community Hospital, Emergency Medicine. Service 2026-09-02 at emergency room (POS 23). Received 2026-10-05.

Needs reviewOut of network

Billed

$3,674.00

3 lines

Allowed

$1,653.30

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Patricia Robertson
Member ID: UHC-63151-88
Date of birth: 1972-02-10
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-431485
Relationship: Self, Eden Prairie, MN

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-2345
Coverage period: 2022-04-01 to present
Deductible: $1,494.27 of $2,500.0060%
Out-of-pocket maximum: $2,928.35 of $7,500.0039%
Copays: office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 9109847134
Network: Out of network
Rendering NPI: 9109847134
Location: Phoenix, AZ · TIN 21-6618841
Authorisation / referral: none / none

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	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,440.00	$648.00	—	—	Review
2	96374 rev 0260	IV push, single drug	—	1	1	$147.00	$66.15	—	—	Review
3	99285 rev 0450	Emergency department visit, high severity with threat to life	—	1	1,2	$2,087.00	$939.15	—	—	Review
Totals						$3,674.00	$1,653.30	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. J18.9 Pneumonia, unspecified organism
3. R10.9 Unspecified abdominal pain

Claim header

Patient account: PA-581657
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-013608 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-02: CHOICE-PLUS-PPO (PPO), effective 2022-04-01.
Timely filing	Pass		Received 33 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	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictat”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Canyon Community Hospital2026-09-02 13:02
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
SystemSystem: Claims system2026-10-05 03:59
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-05 15:49
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-581657.pdf5 pages
Itemised statement totalling $3674.00 across 3 lines.
Er reported_report_PA-581657.pdf3 pages
Emergency department record: triage acuity 3, chief complaint chest pain, unspecified.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Completeness: Documentation incomplete: “Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Note dictat”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-025899	2026-03-22	Summit Clinical Laboratories	$191.00	Approved
CLM-2026-028772	2026-03-23	Heritage Physical Therapy	$558.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity