Claims workbench/CLM-2026-002648

Institutional claim · UB-04 · EDI 837I

CLM-2026-002648

Sunrise Digestive Health Center, Gastroenterology. Service 2026-06-25 at outpatient hospital (POS 22). Received 2026-07-01.

Needs reviewOut of network

Billed

$2,457.00

2 lines

Allowed

$1,105.65

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Review

CO197

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Janet Lewis
Member ID: UHC-35740-35
Date of birth: 1970-10-07
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-431077
Relationship: Spouse, Phoenix, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-3266
Coverage period: 2023-11-01 to present
Deductible: $280.93 of $500.0056%
Out-of-pocket maximum: $334.68 of $1,500.0022%
Copays: office $25.00, specialist $75.00, emergency $350.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 5701797651
Network: Out of network
Rendering NPI: 4741252348
Location: Nashville, TN · TIN 99-4024660
Authorisation / referral: PHONE-914063 / 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	88305 rev 0310	Surgical pathology, level IV	—	1	1	$329.00	$148.05	—	—	Review
2	45378 rev 0750	Colonoscopy, diagnostic	25	1	2	$2,128.00	$957.60	—	—	Review
Totals						$2,457.00	$1,105.65	—	—

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal

Claim header

Patient account: PA-478616
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-009563 (verified, link confidence 1.00).
Eligibility	Pass		Active on 2026-06-25: N/A (PPO), effective 2023-11-01.
Timely filing	Pass		Received 6 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Review	CO197	Authorisation reference “PHONE-914063” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent
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	Pass		Required documentation present.
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: Sunrise Digestive Health Center2026-06-25 12:38
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
SystemSystem: Claims system2026-07-01 01:19
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.

Attachments

Documents received with the claim

Prior auth letterface_sheet_PA-478616.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
Itemized billitemized_PA-478616.pdf8 pages
Itemised statement totalling $2457.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Prior authorisation: Authorisation reference “PHONE-914063” does not match the utilisation-management format; must be confirmed before payment. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

No other claims.

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

PendedCO197scenario: Auth unverifiable

Authorisation must be confirmed with UM before payment.

Review queue Member identity