Claims workbench/CLM-2026-017000

Institutional claim · UB-04 · EDI 837I

CLM-2026-017000

Canyon Regional Medical Center, Emergency Medicine. Service 2026-08-13 at emergency room (POS 23). Received 2026-08-18.

DeniedIdentity on hold: CASE-001450

Billed

$1,902.00

3 lines

Allowed

$1,046.10

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Jason Kelley
Member ID: UHC-48760-69
Date of birth: 1949-01-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-431187
Relationship: Self, Houston, TX

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-2214
Coverage period: 2025-06-01 to 2026-04-16
Deductible: $293.74 of $1,000.0029%
Out-of-pocket maximum: $953.23 of $2,000.0048%
Copays: office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits: 16 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Regional Medical Center
Emergency Medicine · taxonomy 207P00000X
NPI: 7874072318
Network: In network
Rendering NPI: 7874072318
Location: Tampa, FL · TIN 53-7384078
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	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,495.00	$822.25	—	—	DeniedCO27
2	71046 rev 0320	Chest X-ray, two views	—	1	1	$190.00	$104.50	—	—	DeniedCO27
3	96374 rev 0260	IV push, single drug	—	1	1,2	$217.00	$119.35	—	—	DeniedCO27
Totals						$1,902.00	$1,046.10	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. S93.401A Sprain of unspecified ligament of right ankle, initial encounter

Claim header

Patient account: PA-178171
Frequency code: 1 (original)
Accident: Yes
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	Fail	IDQ	Member record is in open steward case CASE-001450; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	CO27	Date of service 2026-08-13 is after coverage terminated on 2026-04-16. Expenses incurred after coverage terminated
Timely filing	Pass		Received 5 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Canyon Regional Medical Center (7874072318).
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: Canyon Regional Medical Center2026-08-13 12:10
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-08-18 01:22

Attachments

Documents received with the claim

Itemized billitemized_PA-178171.pdf5 pages
Itemised statement totalling $1902.00 across 3 lines.
Er reported_report_PA-178171.pdf6 pages
Emergency department record: triage acuity 3, chief complaint unspecified abdominal pain.

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-001450; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-08-13 is after coverage terminated on 2026-04-16.

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity