Claims workbench/CLM-2026-018277

Institutional claim · UB-04 · EDI 837I

CLM-2026-018277

Summit Digestive Health Center, Gastroenterology. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-07-08.

Denied

Billed

$1,999.00

1 line

Allowed

$1,099.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Ann Welch
Member ID: UHC-96949-18
Date of birth: 1990-11-23
Identity: Verified4 records, confidence 0.98
Claim record: CLMCLM-412725
Relationship: Self, Seattle, WA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-8573
Coverage period: 2025-09-01 to present
Deductible: $162.27 of $1,500.0011%
Out-of-pocket maximum: $923.37 of $6,000.0015%
Copays: office $30.00, specialist $60.00, emergency $250.00
Physical therapy visits: 13 of 20 used

Provider

Billing and rendering

Billing provider: Summit Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 1126576986
Network: In network
Rendering NPI: 1189921590
Location: Nashville, TN · TIN 32-9600100
Authorisation / referral: PA2026945539 / REF844005

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	$1,999.00	$1,099.45	—	—	DeniedCO29
Totals						$1,999.00	$1,099.45	—	—

Diagnoses (ICD-10-CM)

1. K58.0 Irritable bowel syndrome with diarrheaprincipal
2. Z12.11 Encounter for screening for malignant neoplasm of colon

Claim header

Patient account: PA-245116
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-002728 (verified, link confidence 0.98).
Eligibility	Pass		Active on 2026-03-08: CORE-HMO (HMO), effective 2025-09-01.
Timely filing	Fail	CO29	Received 122 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		Authorisation PA2026945539 on file for 43239.
Provider network	Pass		In-network provider Summit Digestive Health Center (1126576986).
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: Summit Digestive Health Center2026-03-08 12:39
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-07-08 05:20
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

Prior auth letterPA2026945539_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-08 to 2026-06-06.
Itemized billitemized_PA-245116.pdf4 pages
Itemised statement totalling $1999.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Timely filing: Received 122 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-016602	2026-05-11	Canyon Internal Medicine Associates	$340.00	Denied
CLM-2026-028461	2026-04-06	Meadow Physical Therapy	$190.00	Approved
CLM-2026-020404	2025-12-24	Sunrise Medical Group	$675.00	Denied

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