Claims workbench/CLM-2026-008120

Institutional claim · UB-04 · EDI 837I

CLM-2026-008120

Meadow GI Associates, Gastroenterology. Service 2026-06-21 at outpatient hospital (POS 22). Received 2026-06-24.

DeniedOut of network

Billed

$4,279.00

2 lines

Allowed

$1,925.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Hiroshi Ortega
Member ID: UHC-13898-70
Date of birth: 1992-05-26
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-418069
Relationship: Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan: NULL PPO group GRP-4102
Coverage period: 2025-04-01 to 2026-03-07
Deductible: $1,913.25 of $3,500.0055%
Out-of-pocket maximum: $3,050.56 of $10,500.0029%
Copays: office $40.00, specialist $50.00, emergency $250.00
Physical therapy visits: 3 of 20 used

Provider

Billing and rendering

Billing provider: Meadow GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7747243401
Network: Out of network
Rendering NPI: 9138557258
Location: Los Angeles, CA · TIN 16-0400328
Authorisation / referral: PA2026026340 / 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	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	1	$1,705.00	$767.25	—	—	DeniedCO27
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	1,2	$2,574.00	$1,158.30	—	—	DeniedCO27
Totals						$4,279.00	$1,925.55	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. K58.0 Irritable bowel syndrome with diarrhea

Claim header

Patient account: PA-533504
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-022040 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-06-21 is after coverage terminated on 2026-03-07. Expenses incurred after coverage terminated
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 PA2026026340 on file for 43239, 45378.
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Meadow GI Associates2026-06-21 15:00
Patient seen for gastro-esophageal reflux disease without esophagitis.
SystemSystem: Claims system2026-06-24 06:54
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-24 14:13
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026026340_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-06-21 to 2026-09-19.
Itemized billitemized_PA-533504.pdf8 pages
Itemised statement totalling $4279.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-06-21 is after coverage terminated on 2026-03-07. 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

Claim	Service	Provider	Billed	Status
CLM-2026-030150	2026-03-09	Summit Diagnostic Imaging	$1,491.00	Denied

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity