Claims workbench/CLM-2026-021622

Institutional claim · UB-04 · EDI 837I

CLM-2026-021622

Riverside Digestive Health Center, Gastroenterology. Service 2026-08-03 at outpatient hospital (POS 22). Received 2026-09-30.

Denied

Billed

$1,936.00

1 line

Allowed

$1,064.80

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Mariana Delgado
Member ID: UHC-65759-31
Date of birth: 1968-03-12
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-406206
Relationship: Self, Nashville, TN

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-4870
Coverage period: 2021-12-01 to present
Deductible: $131.74 of $500.0026%
Out-of-pocket maximum: $457.83 of $2,000.0023%
Copays: office $25.00, specialist $75.00, emergency $350.00
Physical therapy visits: 8 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 8834777772
Network: In network
Rendering NPI: 1234430308
Location: Tempe, AZ · TIN 41-1081863
Authorisation / referral: PA2025976655 / 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	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	1	$1,936.00	$1,064.80	—	—	DeniedCO18
Totals						$1,936.00	$1,064.80	—	—

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-997740
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-022672 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-08-03: - (PPO), effective 2021-12-01.
Timely filing	Pass		Received 58 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-021621: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025976655 on file for 43239.
Provider network	Pass		In-network provider Riverside Digestive Health Center (8834777772).
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. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Digestive Health Center2026-08-03 14:36
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-09-30 02:18
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-30 14:34
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025976655_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-03 to 2026-11-01.
Itemized billitemized_PA-997740.pdf6 pages
Itemised statement totalling $1936.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-021621: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-021621	2026-08-03	Riverside Digestive Health Center	$1,936.00	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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity