Claims workbench/CLM-2026-011039

Institutional claim · UB-04 · EDI 837I

CLM-2026-011039

Unity Digestive Health Center, Gastroenterology. Service 2026-01-22 at outpatient hospital (POS 22). Received 2026-01-29.

PendedIdentity on hold: CASE-002010

Billed

$3,128.00

2 lines

Allowed

$1,720.40

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Gloria Fowler
Member ID: UHC-72716-32
Date of birth: 1964-09-07
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-407421
Relationship: Self

Coverage and accumulators

Found by member ID

Plan: UNKNOWN PPO group GRP-8358
Coverage period: 2021-08-01 to present
Deductible: $1,344.77 of $1,500.0090%
Out-of-pocket maximum: $2,034.51 of $4,500.0045%
Copays: office $40.00, specialist $75.00, emergency $150.00
Physical therapy visits: 2 of 20 used

Provider

Billing and rendering

Billing provider: Unity Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 9735187566
Network: In network
Rendering NPI: 7023219489
Location: Austin, TX · TIN 73-9134731
Authorisation / referral: PA2025525921 / 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	70553 rev 0610	MRI brain with and without contrast	—	1	1	$2,843.00	$1,563.65	—	—	PendedIDQ
2	88305 rev 0310	Surgical pathology, level IV	—	1	1	$285.00	$156.75	—	—	PendedIDQ
Totals						$3,128.00	$1,720.40	—	—

Diagnoses (ICD-10-CM)

1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal

Claim header

Patient account: PA-743572
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	Fail	IDQ	Member record is in open steward case CASE-002010; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Pass		Active on 2026-01-22: UNKNOWN (PPO), effective 2021-08-01.
Timely filing	Pass		Received 7 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025525921 on file for 70553.
Provider network	Pass		In-network provider Unity Digestive Health Center (9735187566).
Medical necessity	Review	CO50	70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Digestive Health Center2026-01-22 18:08
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.
SystemSystem: Claims system2026-01-29 02:59
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-29 13:56
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025525921_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-22 to 2026-04-22.
Itemized billitemized_PA-743572.pdf9 pages
Itemised statement totalling $3128.00 across 2 lines.
Medical recordrecords_PA-743572.pdf10 pages
Clinic notes for a routine annual visit; no symptoms documented.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-002010; payment withheld until the identity is confirmed. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.

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

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

DeniedCO50scenario: Dx mismatch

Routine diagnosis does not support advanced imaging.

Review queue Member identity