Claims workbench/CLM-2026-021610

Institutional claim · UB-04 · EDI 837I

CLM-2026-021610

Sunrise Digestive Health Center, Gastroenterology. Service 2026-02-02 at outpatient hospital (POS 22). Received 2026-02-13.

DeniedOut of network

Billed

$4,174.00

2 lines

Allowed

$1,878.30

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Julie Nunez
Member ID: UHC-39256-14
Date of birth: 1942-09-10
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-426240
Relationship: Child, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-8211
Coverage period: 2023-07-01 to present
Deductible: $274.74 of $1,000.0027%
Out-of-pocket maximum: $1,261.91 of $3,000.0042%
Copays: office $30.00, specialist $50.00, emergency $250.00
Physical therapy visits: 9 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 5701797651
Network: Out of network
Rendering NPI: 8147303910
Location: Nashville, TN · TIN 99-4024660
Authorisation / referral: PA2026261846 / REF992045

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	$1,609.00	$724.05	—	—	DeniedCO204
2	43239 rev 0750	Upper GI endoscopy with biopsy	25	1	1,2	$2,565.00	$1,154.25	—	—	DeniedCO204
Totals						$4,174.00	$1,878.30	—	—

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
2. K21.9 Gastro-esophageal reflux disease without esophagitis

Claim header

Patient account: PA-859126
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-012743 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-02-02: CORE-HMO (HMO), effective 2023-07-01.
Timely filing	Pass		Received 11 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026261846 on file for 45378, 43239.
Provider network	Fail	CO204	Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan
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: Sunrise Digestive Health Center2026-02-02 11:22
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-02-13 03:43
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.

Attachments

Documents received with the claim

Prior auth letterPA2026261846_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-02 to 2026-05-03.
Itemized billitemized_PA-859126.pdf8 pages
Itemised statement totalling $4174.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Provider network: Billing provider 5701797651 is out of network and the HMO plan has no out-of-network benefit.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-024785	2026-01-26	Unity Physical Therapy	$186.00	Approved

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

DeniedCO204scenario: Oon hmo

No out-of-network benefit on this plan.

Review queue Member identity