Claims workbench/CLM-2026-019085

Institutional claim · UB-04 · EDI 837I

CLM-2026-019085

Heritage Digestive Health Center, Gastroenterology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-27.

Needs review

Billed

$5,162.00

3 lines

Allowed

$2,839.10

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Kelly Miller
Member ID: UHC-14354-74
Date of birth: 1970-07-10
Identity: Verified3 records, confidence 0.96
Claim record: CLMCLM-430569
Relationship: Self, Gilbert, AZ

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-3363
Coverage period: 2024-01-01 to present
Deductible: $1,973.71 of $2,500.0079%
Out-of-pocket maximum: $2,300.78 of $7,500.0031%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 12 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 4437349366
Network: In network
Rendering NPI: 2119486316
Location: San Diego, CA · TIN 67-1701611
Authorisation / referral: PA2025853626 / REF122941

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	$2,328.00	$1,280.40	—	—	Review
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	1,2	$2,509.00	$1,379.95	—	—	Review
3	88305 rev 0310	Surgical pathology, level IV	25	1	1,2	$325.00	$178.75	—	—	Review
Totals						$5,162.00	$2,839.10	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-396326
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

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-001766 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-30: NAVIGATE-HMO (HMO), effective 2024-01-01.
Timely filing	Pass		Received 28 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-019084, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2025853626 on file for 43239, 45378.
Provider network	Pass		In-network provider Heritage Digestive Health Center (4437349366).
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Digestive Health Center2025-12-30 12:35
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-01-27 06:39
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-27 17:44
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025853626_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-30 to 2026-03-30.
Itemized billitemized_PA-396326.pdf8 pages
Itemised statement totalling $5162.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-019084, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019084	2025-12-30	Sunrise GI Associates	$5,162.00	Approved

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

Approvedscenario: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity