Claims workbench/CLM-2026-013094

Institutional claim · UB-04 · EDI 837I

CLM-2026-013094

Evergreen Digestive Health Center, Gastroenterology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-06-16.

DeniedIdentity on hold: CASE-004083

Billed

$255.00

1 line

Allowed

$140.25

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: Priya Ortiz
Member ID: none on golden record
Date of birth: 1946-06-05
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-407424
Relationship: Spouse, Tucson, AZ

Coverage and accumulators

Found by name and date of birth

Plan: SELECT-EPO EPO group GRP-4216
Coverage period: 2025-07-01 to present
Deductible: $199.89 of $1,500.0013%
Out-of-pocket maximum: $281.92 of $4,500.006%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 13 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 7438481310
Network: In network
Rendering NPI: 1088967124
Location: San Diego, CA · TIN 71-8732123
Authorisation / referral: none / 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	88305 rev 0310	Surgical pathology, level IV	—	1	1	$255.00	$140.25	—	—	DeniedCO29
Totals						$255.00	$140.25	—	—

Diagnoses (ICD-10-CM)

1. K58.0 Irritable bowel syndrome with diarrheaprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-986425
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-004083; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-01-07: SELECT-EPO (EPO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Fail	CO29	Received 160 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		No line requires precertification.
Provider network	Pass		In-network provider Evergreen Digestive Health Center (7438481310).
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: Evergreen Digestive Health Center2026-01-07 16:36
Patient seen for irritable bowel syndrome with diarrhea.
SystemSystem: Claims system2026-06-16 03:36
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-06-16 16:51
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Itemized billitemized_PA-986425.pdf8 pages
Itemised statement totalling $255.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-004083; payment withheld until the identity is confirmed. Eligibility: Active on 2026-01-07: SELECT-EPO (EPO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Timely filing: Received 160 days after the last date of service (limit 90).

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity