Claims workbench/CLM-2026-018027
Institutional claim · UB-04 · EDI 837I

CLM-2026-018027

Heritage Digestive Health Center, Gastroenterology. Service 2026-08-18 at outpatient hospital (POS 22). Received 2026-10-01.

Pended
Billed
$2,289.00
2 lines
Allowed
$1,258.95
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Nicole Park
Member ID
none on golden record
Date of birth
1990-09-14
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-402753
Relationship
Self, Mesa, AZ

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Heritage Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI
4437349366
Network
In network
Rendering NPI
1917909651
Location
San Diego, CA · TIN 67-1701611
Authorisation / referral
PA2026018075 / none

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
143239
rev 0750
Upper GI endoscopy with biopsy—11$1,995.00$1,097.25——PendedN30
288305
rev 0310
Surgical pathology, level IV—11$294.00$161.70——PendedN30
Totals$2,289.00$1,258.95——
Diagnoses (ICD-10-CM)
  • 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
Claim header
Patient account
PA-678233
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-021812 (verified, link confidence 1.00).
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 44 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026018075 on file for 43239.
Provider networkPassIn-network provider Heritage Digestive Health Center (4437349366).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin 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 Digestive Health Center2026-08-18 14:37

    Patient seen for irritable bowel syndrome with diarrhea.

Attachments

Documents received with the claim

  • Prior auth letterPA2026018075_approval.pdf2 pages

    Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-18 to 2026-11-16.

  • Itemized billitemized_PA-678233.pdf9 pages

    Itemised statement totalling $2289.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Eligibility: No coverage segment found for the member ID on this 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

Record the final decision; pricing and remittance reasons follow from it

Outcome
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: Clean

Clean claim, priced at contract rate.

Review queueMember identity