Claims workbench/CLM-2026-013070

Professional claim · CMS-1500 · EDI 837P

CLM-2026-013070

Heritage GI Associates, Gastroenterology. Service 2026-03-07 at office (POS 11). Received 2026-04-14.

PendedIdentity on hold: CASE-003757

Billed

$2,430.00

2 lines

Allowed

$1,506.60

if approved

Plan pays

—

Pended

Member owes

—

no coverage

Rules engine

Pend

IDQ, N30

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: William Wong
Member ID: none on golden record
Date of birth: 1981-05-15
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-428645
Relationship: Self, Scottsdale, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Heritage GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 8459983820
Network: In network
Rendering NPI: 3565555851
Location: Tempe, AZ · TIN 81-8461121
Authorisation / referral: PA2026586575 / REF793762

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99214	Office visit, established patient, moderate complexity	59	1	1	$214.00	$132.68	—	—	PendedIDQ
2	43239 rev 0750	Upper GI endoscopy with biopsy	59	1	1,2	$2,216.00	$1,373.92	—	—	PendedIDQ
Totals						$2,430.00	$1,506.60	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-115427
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003757; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 38 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026586575 on file for 43239.
Provider network	Pass		In-network provider Heritage GI Associates (8459983820).
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. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage GI Associates2026-03-07 18:47
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-04-14 03:28
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-14 12:21
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026586575_approval.pdf2 pages
Utilisation management approval letter for 99214 (Office visit, established patient, moderate complexity), valid 2026-03-07 to 2026-06-05.
Medical recordrecords_PA-115427.pdf4 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-21 13:43
Member identity: Member record is in open steward case CASE-003757; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. 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

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

Approvedscenario: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity