Claims workbench/CLM-2026-024401

Institutional claim · UB-04 · EDI 837I

CLM-2026-024401

Canyon Community Hospital, Emergency Medicine. Service 2026-09-26 at emergency room (POS 23). Received 2026-10-07.

DeniedOut of network

Billed

$1,478.00

1 line

Allowed

$812.90

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Brandon Boyd
Member ID: UHC-74380-08
Date of birth: 1988-06-11
Identity: Verified4 records, confidence 0.99
Claim record: CLMCLM-407560
Relationship: Self, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan: SELECT-EPO EPO group GRP-8463
Coverage period: 2024-10-01 to 2026-07-16
Deductible: $464.37 of $1,000.0046%
Out-of-pocket maximum: $224.69 of $3,000.007%
Copays: office $25.00, specialist $60.00, emergency $250.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Canyon Community Hospital
Emergency Medicine · taxonomy 207P00000X
NPI: 9109847134
Network: Out of network
Rendering NPI: 9109847134
Location: Phoenix, AZ · TIN 21-6618841
Authorisation / referral: none / 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	99284 rev 0450	Emergency department visit, high severity	—	1	1	$1,478.00	$812.90	—	—	DeniedCO27
Totals						$1,478.00	$812.90	—	—

Diagnoses (ICD-10-CM)

1. R10.9 Unspecified abdominal painprincipal
2. R55 Syncope and collapse
3. J18.9 Pneumonia, unspecified organism

Claim header

Patient account: PA-942109
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-022233 (verified, link confidence 0.99).
Eligibility	Fail	CO27	Date of service 2026-09-26 is after coverage terminated on 2026-07-16. Expenses incurred after coverage terminated
Timely filing	Pass		Received 11 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		No line requires precertification.
Provider network	Review	NET	Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record. Out-of-network provider
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: Canyon Community Hospital2026-09-26 12:09
Patient seen for unspecified abdominal pain.
SystemSystem: Claims system2026-10-07 02:45
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-07 13:28
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Itemized billitemized_PA-942109.pdf3 pages
Itemised statement totalling $1478.00 across 1 line.
Er reported_report_PA-942109.pdf5 pages
Emergency department record: triage acuity 4, chief complaint unspecified abdominal pain.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-09-26 is after coverage terminated on 2026-07-16. Provider network: Out-of-network emergency visit. Payable at the in-network level if the prudent-layperson standard is met; review the ED record.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-019875	2026-08-12	Evergreen Internal Medicine Associates	$94.00	Denied

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity