Claims workbench/CLM-2026-012628

Institutional claim · UB-04 · EDI 837I

CLM-2026-012628

Sunrise Digestive Health Center, Gastroenterology. Service 2026-09-03 at outpatient hospital (POS 22). Received 2026-09-24.

Needs reviewOut of network

Billed

$3,858.00

3 lines

Allowed

$1,736.10

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Gary Fields
Member ID: UHC-65382-80
Date of birth: 1988-08-24
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-426591
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-7846
Coverage period: 2024-11-01 to present
Deductible: $1,119.12 of $3,500.0032%
Out-of-pocket maximum: $2,132.54 of $7,000.0030%
Copays: office $20.00, specialist $60.00, emergency $350.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 5701797651
Network: Out of network
Rendering NPI: 2956227963
Location: Nashville, TN · TIN 99-4024660
Authorisation / referral: PA2026564009 / 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	59	1	1	$1,792.00	$806.40	—	—	Review
2	88305 rev 0310	Surgical pathology, level IV	59	1	2	$291.00	$130.95	—	—	Review
3	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	2	$1,775.00	$798.75	—	—	Review
Totals						$3,858.00	$1,736.10	—	—

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-636916
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-013658 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-03: OPTIONS-PPO (PPO), effective 2024-11-01.
Timely filing	Pass		Received 21 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026564009 on file for 45378, 43239.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Sunrise Digestive Health Center2026-09-03 14:10
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-09-24 00:16
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Prior auth letterPA2026564009_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-03 to 2026-12-02.
Itemized billitemized_PA-636916.pdf9 pages
Itemised statement totalling $3858.00 across 3 lines.
Medical recordrecords_PA-636916.pdf6 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-004617	2026-09-14	Unity Primary Care Associates	$236.00	Approved
CLM-2026-034601	2026-01-19	Valley Heart Institute	$3,816.00	Needs review

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

Approvedscenario: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity