Claims workbench/CLM-2026-013922

Institutional claim · UB-04 · EDI 837I

CLM-2026-013922

Evergreen Digestive Health Center, Gastroenterology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-08-13.

Denied

Billed

$4,179.00

3 lines

Allowed

$2,298.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO197

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Carol Weber
Member ID: UHC-25986-60
Date of birth: 1988-09-28
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-425241
Relationship: Self, Columbus, OH

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-5431
Coverage period: 2021-02-01 to present
Deductible: $324.25 of $500.0065%
Out-of-pocket maximum: $66.97 of $1,500.004%
Copays: office $25.00, specialist $40.00, emergency $150.00
Physical therapy visits: 1 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 7438481310
Network: In network
Rendering NPI: 4040248583
Location: San Diego, CA · TIN 71-8732123
Authorisation / referral: none / REF679425

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	$1,773.00	$975.15	—	—	DeniedCO197
2	88305 rev 0310	Surgical pathology, level IV	—	1	2	$285.00	$156.75	—	—	DeniedCO197
3	45378 rev 0750	Colonoscopy, diagnostic	—	1	2	$2,121.00	$1,166.55	—	—	DeniedCO197
Totals						$4,179.00	$2,298.45	—	—

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-413259
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-039592 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-03: CORE-HMO (HMO), effective 2021-02-01.
Timely filing	Pass		Received 10 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Fail	CO197	43239, 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent
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 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Digestive Health Center2026-08-03 17:51
Patient seen for encounter for screening for malignant neoplasm of colon.
SystemSystem: Claims system2026-08-13 05:57
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.

Attachments

Documents received with the claim

Itemized billitemized_PA-413259.pdf6 pages
Itemised statement totalling $4179.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Prior authorisation: 43239, 45378 require precertification; no authorisation number on the claim.

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

DeniedCO197scenario: No auth

Precertification required and absent.

Review queue Member identity