Claims workbench/CLM-2026-004056

Institutional claim · UB-04 · EDI 837I

CLM-2026-004056

Riverside Digestive Health Center, Gastroenterology. Service 2026-03-04 at outpatient hospital (POS 22). Received 2026-03-07.

PendedIdentity on hold: CASE-003147

Billed

$2,131.00

2 lines

Allowed

$1,172.05

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Vincent Salazar
Member ID: none on golden record
Date of birth: 1995-11-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-401995
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: CORE-HMO HMO group GRP-4008
Coverage period: 2025-05-01 to present
Deductible: $402.12 of $500.0080%
Out-of-pocket maximum: $533.90 of $2,000.0027%
Copays: office $20.00, specialist $50.00, emergency $150.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 8834777772
Network: In network
Rendering NPI: 7701587413
Location: Tempe, AZ · TIN 41-1081863
Authorisation / referral: PA2026531117 / REF155710

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	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	1	$1,831.00	$1,007.05	—	—	PendedIDQ
2	88305 rev 0310	Surgical pathology, level IV	—	1	2	$300.00	$165.00	—	—	PendedIDQ
Totals						$2,131.00	$1,172.05	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal

Claim header

Patient account: PA-369437
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	Fail	IDQ	Member record is in open steward case CASE-003147; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-03-04: CORE-HMO (HMO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 3 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026531117 on file for 43239.
Provider network	Pass		In-network provider Riverside Digestive Health Center (8834777772).
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. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Digestive Health Center2026-03-04 18:04
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2026531117_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-04 to 2026-06-02.
Itemized billitemized_PA-369437.pdf7 pages
Itemised statement totalling $2131.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-003147; payment withheld until the identity is confirmed. Eligibility: Active on 2026-03-04: CORE-HMO (HMO), effective 2025-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.

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

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