Claims workbench/CLM-2026-008787

Institutional claim · UB-04 · EDI 837I

CLM-2026-008787

Riverside GI Associates, Gastroenterology. Service 2026-08-23 at outpatient hospital (POS 22). Received 2026-08-25.

Denied

Billed

$4,411.00

3 lines

Allowed

$2,426.05

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: Jesse Gardner
Member ID: UHC-82310-03
Date of birth: 1984-12-15
Identity: Verified3 records, confidence 0.93
Claim record: CLMCLM-404756
Relationship: Self, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group UNKNOWN
Coverage period: 2022-01-01 to 2026-06-12
Deductible: $73.55 of $500.0015%
Out-of-pocket maximum: $358.28 of $2,000.0018%
Copays: office $30.00, specialist $75.00, emergency $250.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Riverside GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7858029219
Network: In network
Rendering NPI: 3062456934
Location: San Diego, CA · TIN 69-3440792
Authorisation / referral: PA2026779408 / 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	$1,598.00	$878.90	—	—	DeniedCO27
2	88305 rev 0310	Surgical pathology, level IV	—	1	1	$314.00	$172.70	—	—	DeniedCO27
3	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	2	$2,499.00	$1,374.45	—	—	DeniedCO27
Totals						$4,411.00	$2,426.05	—	—

Diagnoses (ICD-10-CM)

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

Claim header

Patient account: PA-651204
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-014411 (verified, link confidence 0.93).
Eligibility	Fail	CO27	Date of service 2026-08-23 is after coverage terminated on 2026-06-12. Expenses incurred after coverage terminated
Timely filing	Pass		Received 2 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026779408 on file for 45378, 43239.
Provider network	Pass		In-network provider Riverside GI Associates (7858029219).
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: Riverside GI Associates2026-08-23 14:43
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-08-25 02:33
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-25 12:02
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2026779408_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-23 to 2026-11-21.
Itemized billitemized_PA-651204.pdf4 pages
Itemised statement totalling $4411.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Eligibility: Date of service 2026-08-23 is after coverage terminated on 2026-06-12.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-023125	2026-01-31	Summit Imaging Center	$225.00	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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity