Claims workbench/CLM-2026-010448

Institutional claim · UB-04 · EDI 837I

CLM-2026-010448

Meadow GI Associates, Gastroenterology. Service 2026-09-26 at outpatient hospital (POS 22). Received 2026-10-10.

DeniedOut of network

Billed

$4,718.00

3 lines

Allowed

$2,123.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Judy Rose
Member ID: UHC-80661-85
Date of birth: 1960-02-14
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-404347
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-0944
Coverage period: 2022-11-01 to present
Deductible: $1,334.01 of $3,500.0038%
Out-of-pocket maximum: $3,659.53 of $14,000.0026%
Copays: office $40.00, specialist $75.00, emergency $250.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Meadow GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7747243401
Network: Out of network
Rendering NPI: 1815478619
Location: Los Angeles, CA · TIN 16-0400328
Authorisation / referral: PA2025586746 / 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	$2,562.00	$1,152.90	—	—	DeniedCO204
2	88305 rev 0310	Surgical pathology, level IV	—	1	1	$326.00	$146.70	—	—	DeniedCO204
3	45378 rev 0750	Colonoscopy, diagnostic	—	1	2	$1,830.00	$823.50	—	—	DeniedCO204
Totals						$4,718.00	$2,123.10	—	—

Diagnoses (ICD-10-CM)

1. R10.13 Epigastric painprincipal

Claim header

Patient account: PA-464250
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-002796 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-26: SELECT-EPO (EPO), effective 2022-11-01.
Timely filing	Pass		Received 14 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025586746 on file for 43239, 45378.
Provider network	Fail	CO204	Billing provider 7747243401 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan
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 Associates2026-09-26 16:54
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-10-10 01:11
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-10 14:13
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2025586746_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-09-26 to 2026-12-25.
Itemized billitemized_PA-464250.pdf8 pages
Itemised statement totalling $4718.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 7747243401 is out of network and the EPO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

No other claims.

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity