Claims workbench/CLM-2026-010295

Institutional claim · UB-04 · EDI 837I

CLM-2026-010295

Mesa GI Associates, Gastroenterology. Service 2025-12-24 at outpatient hospital (POS 22). Received 2026-06-26.

Denied

Billed

$1,615.00

1 line

Allowed

$888.25

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Nicholas Carter
Member ID: UHC-84056-95
Date of birth: 1938-12-23
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-403125
Relationship: Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-9202
Coverage period: 2023-07-01 to present
Deductible: $3,054.46 of $3,500.0087%
Out-of-pocket maximum: $1,347.16 of $14,000.0010%
Copays: office $40.00, specialist $40.00, emergency $350.00
Physical therapy visits: 17 of 20 used

Provider

Billing and rendering

Billing provider: Mesa GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7557205672
Network: In network
Rendering NPI: 9891435833
Location: Phoenix, AZ · TIN 12-8480573
Authorisation / referral: PA2025453374 / 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	$1,615.00	$888.25	—	—	DeniedCO29
Totals						$1,615.00	$888.25	—	—

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-207118
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-015183 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-12-24: UNKNOWN (PPO), effective 2023-07-01.
Timely filing	Fail	CO29	Received 184 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025453374 on file for 45378.
Provider network	Pass		In-network provider Mesa GI Associates (7557205672).
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: Mesa GI Associates2025-12-24 12:40
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-26 01:57
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-26 08:25
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025453374_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2025-12-24 to 2026-03-24.
Itemized billitemized_PA-207118.pdf3 pages
Itemised statement totalling $1615.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 184 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-012999	2026-04-15	Heritage Community Hospital	$717.00	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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity