Claims workbench/CLM-2026-006904

Institutional claim · UB-04 · Paper

CLM-2026-006904

Meadow GI Associates, Gastroenterology. Service 2025-12-18 at outpatient hospital (POS 22). Received 2026-02-01.

Denied

Billed

$2,897.00

2 lines

Allowed

$1,593.35

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Teresa Fisher
Member ID: UHC-20504-81
Date of birth: 1959-04-26
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-425718
Relationship: Self, Scottsdale, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-1960
Coverage period: 2023-02-01 to present
Deductible: $1,282.05 of $1,500.0085%
Out-of-pocket maximum: $1,309.14 of $4,500.0029%
Copays: office $25.00, specialist $50.00, emergency $350.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Meadow GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 1813475971
Network: In network
Rendering NPI: 1170160984
Location: Austin, TX · TIN 38-1568789
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	88305 rev 0310	Surgical pathology, level IV	—	1	1	$289.00	$158.95	—	—	DeniedCO197
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	1	$2,608.00	$1,434.40	—	—	DeniedCO197
Totals						$2,897.00	$1,593.35	—	—

Diagnoses (ICD-10-CM)

1. K58.0 Irritable bowel syndrome with diarrheaprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-981734
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-009576 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-18: CHOICE-PLUS-PPO (PPO), effective 2023-02-01.
Timely filing	Pass		Received 45 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	45378 require precertification; no authorisation number on the claim. Precertification or authorization absent
Provider network	Pass		In-network provider Meadow GI Associates (1813475971).
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: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow GI Associates2025-12-18 16:24
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-02-01 06:04
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-01 12:23
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-981734.pdf8 pages
Itemised statement totalling $2897.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Prior authorisation: 45378 require precertification; no authorisation number on the claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-016834	2026-08-11	Evergreen Reference Lab	$244.00	Needs review
CLM-2026-009196	2026-08-20	Cornerstone Reference Lab	$132.00	Approved
CLM-2026-013543	2026-07-24	Northgate Internal Medicine Associates	$242.00	Approved
CLM-2026-032274	2026-05-26	Harbor Reference Lab	$98.00	Approved

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied 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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity