Claims workbench/CLM-2026-008606

Institutional claim · UB-04 · EDI 837I

CLM-2026-008606

Harbor Digestive Health Center, Gastroenterology. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-09-16.

Needs review

Billed

$1,984.00

1 line

Allowed

$1,091.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Jonathan Hughes
Member ID: UHC-60893-02
Date of birth: 1980-01-09
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-418292
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-0450
Coverage period: 2021-10-01 to present
Deductible: $62.86 of $500.0013%
Out-of-pocket maximum: $665.39 of $2,000.0033%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Harbor Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 7922422671
Network: In network
Rendering NPI: 4907654923
Location: Tempe, AZ · TIN 89-3478747
Authorisation / referral: PA2026510439 / 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	45378 rev 0750	Colonoscopy, diagnostic	—	1	1	$1,984.00	$1,091.20	—	—	Review
Totals						$1,984.00	$1,091.20	—	—

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
2. K21.9 Gastro-esophageal reflux disease without esophagitis

Claim header

Patient account: PA-737416
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-002507 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-18: CHOICE-PLUS-PPO (PPO), effective 2021-10-01.
Timely filing	Pass		Received 29 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026510439 on file for 45378.
Provider network	Pass		In-network provider Harbor Digestive Health Center (7922422671).
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: “Established patient presents with encounter for screening for malignant neoplasm of colon;”. 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: Harbor Digestive Health Center2026-08-18 09:03
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-09-16 06:49
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-16 14:42
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026510439_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-18 to 2026-11-16.
Itemized billitemized_PA-737416.pdf6 pages
Itemised statement totalling $1984.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Completeness: Documentation incomplete: “Established patient presents with encounter for screening for malignant neoplasm of colon;”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005704	2026-06-09	Meadow Primary Care Associates	$268.00	Approved
CLM-2026-022721	2026-06-09	Mesa Physical Therapy	$140.00	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