Claims workbench/CLM-2026-018002

Institutional claim · UB-04 · EDI 837I

CLM-2026-018002

Canyon GI Associates, Gastroenterology. Service 2026-04-08 at outpatient hospital (POS 22). Received 2026-05-08.

Needs review

Billed

$2,824.00

2 lines

Allowed

$1,553.20

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO16

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Amber Tucker
Member ID: UHC-44715-06
Date of birth: 1995-05-03
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-406342
Relationship: Self, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-2316
Coverage period: 2024-12-01 to present
Deductible: $290.14 of $2,500.0012%
Out-of-pocket maximum: $962.34 of $5,000.0019%
Copays: office $20.00, specialist $50.00, emergency $250.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Canyon GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 8906815153
Network: In network
Rendering NPI: 5167773295
Location: Minneapolis, MN · TIN 78-1003957
Authorisation / referral: PA2026079456 / REF892489

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	$314.00	$172.70	—	—	Review
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	2	$2,510.00	$1,380.50	—	—	Review
Totals						$2,824.00	$1,553.20	—	—

Diagnoses (ICD-10-CM)

1. R10.13 Epigastric painprincipal
2. K58.0 Irritable bowel syndrome with diarrhea

Claim header

Patient account: PA-899345
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-018709 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-04-08: CORE-HMO (HMO), effective 2024-12-01.
Timely filing	Pass		Received 30 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026079456 on file for 45378.
Provider network	Pass		In-network provider Canyon GI Associates (8906815153).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Pass		No bundling conflicts.
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Review	CO16	Documentation incomplete: “Established patient presents with epigastric pain; symptoms reviewed and vitals within exp”. Claim lacks information needed for adjudication
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Canyon GI Associates2026-04-08 13:23
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
SystemSystem: Claims system2026-05-08 04:40
Rendering provider signature missing on the attached note. Development letter sent to provider.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-08 11:10
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2026079456_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-04-08 to 2026-07-07.
Itemized billitemized_PA-899345.pdf6 pages
Itemised statement totalling $2824.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Completeness: Documentation incomplete: “Established patient presents with epigastric pain; symptoms reviewed and vitals within exp”.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-030538	2026-05-06	Meadow Reference Lab	$134.00	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

PendedCO16scenario: Missing info

Development letter outstanding.

Review queue Member identity