Claims workbench/CLM-2026-020596

Institutional claim · UB-04 · EDI 837I

CLM-2026-020596

Sunrise Digestive Health Center, Gastroenterology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-06-22.

Needs reviewReplacement of CLM-2026-020595Out of network

Billed

$1,998.00

2 lines

Allowed

$899.10

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Christopher Meyer
Member ID: UHC-42589-19
Date of birth: 1997-06-28
Identity: Verified3 records, confidence 0.97
Claim record: CLMCLM-431155
Relationship: Self, Mesa, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7987
Coverage period: 2023-01-01 to present
Deductible: $455.91 of $3,500.0013%
Out-of-pocket maximum: $56.86 of $10,500.001%
Copays: office $25.00, specialist $40.00, emergency $350.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 5701797651
Network: Out of network
Rendering NPI: 9821931943
Location: Nashville, TN · TIN 99-4024660
Authorisation / referral: PA2026853582 / 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	$1,680.00	$756.00	—	—	Review
2	88305 rev 0310	Surgical pathology, level IV	—	1	2	$318.00	$143.10	—	—	Review
Totals						$1,998.00	$899.10	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. K58.0 Irritable bowel syndrome with diarrhea

Claim header

Patient account: PA-474171
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-034917 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-05-10: CHOICE-PLUS-PPO (PPO), effective 2023-01-01.
Timely filing	Pass		Received 43 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-020595; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
Prior authorisation	Pass		Authorisation PA2026853582 on file for 45378.
Provider network	Note		Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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: Sunrise Digestive Health Center2026-05-10 11:00
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-06-22 06:27
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Prior auth letterPA2026853582_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-05-10 to 2026-08-08.
Itemized billitemized_PA-474171.pdf8 pages
Itemised statement totalling $1998.00 across 2 lines.
Corrected claimcorrected_CLM-2026-020595.pdf1 page
Provider cover letter requesting replacement of CLM-2026-020595.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-020595; the original must be voided when this adjudicates. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020595	2026-05-10	Sunrise Digestive Health Center	$1,998.00	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: Replacement

Replacement claim supersedes the original.

Review queue Member identity