Claims workbench/CLM-2026-019362

Institutional claim · UB-04 · EDI 837I

CLM-2026-019362

Cornerstone Digestive Health Center, Gastroenterology. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-09.

DeniedIdentity on hold: CASE-003514

Billed

$2,027.00

1 line

Allowed

$1,114.85

if approved

Plan pays

—

Denied

Member owes

—

no coverage

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Anna Ortega
Member ID: none on golden record
Date of birth: 1998-07-16
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-415593
Relationship: Self, Las Vegas, NV

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider: Cornerstone Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 4838407417
Network: In network
Rendering NPI: 8433801577
Location: Los Angeles, CA · TIN 73-5559083
Authorisation / referral: PA2025428882 / 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	45378 rev 0750	Colonoscopy, diagnostic	—	1	1	$2,027.00	$1,114.85	—	—	DeniedCO18
Totals						$2,027.00	$1,114.85	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal

Claim header

Patient account: PA-992522
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 3 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-003514; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	N30	No coverage segment found for the member ID on this claim. Patient ineligible for this service
Timely filing	Pass		Received 19 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-019361: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025428882 on file for 45378.
Provider network	Pass		In-network provider Cornerstone Digestive Health Center (4838407417).
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: Cornerstone Digestive Health Center2026-07-21 11:36
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-08-09 01:35
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-09 12:50
Member services inquiry logged on this claim; member asked about the status of payment.

Attachments

Documents received with the claim

Prior auth letterPA2025428882_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-21 to 2026-10-19.
Itemized billitemized_PA-992522.pdf4 pages
Itemised statement totalling $2027.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Member identity: Member record is in open steward case CASE-003514; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Duplicate check: Exact duplicate of CLM-2026-019361: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019361	2026-07-21	Cornerstone Digestive Health Center	$2,027.00	Pended

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity