Claims workbench/CLM-2026-026473

Institutional claim · UB-04 · EDI 837I

CLM-2026-026473

Heritage GI Associates, Gastroenterology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-02.

Denied

Billed

$1,939.00

2 lines

Allowed

$1,066.45

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Alice Murphy
Member ID: UHC-19582-46
Date of birth: 1967-09-28
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-407580
Relationship: Self, Tampa, FL

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-0770
Coverage period: 2024-09-01 to present
Deductible: $561.75 of $2,500.0022%
Out-of-pocket maximum: $2,165.09 of $10,000.0022%
Copays: office $25.00, specialist $50.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Heritage GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 8459983820
Network: In network
Rendering NPI: 7402960901
Location: Tempe, AZ · TIN 81-8461121
Authorisation / referral: PA2025148408 / REF570702

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	88305 rev 0310	Surgical pathology, level IV	—	1	1	$222.00	$122.10	—	—	DeniedCO18
2	43239 rev 0750	Upper GI endoscopy with biopsy	—	1	2	$1,717.00	$944.35	—	—	DeniedCO18
Totals						$1,939.00	$1,066.45	—	—

Diagnoses (ICD-10-CM)

1. R10.13 Epigastric painprincipal
2. K58.0 Irritable bowel syndrome with diarrhea

Claim header

Patient account: PA-644643
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-006115 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-01-07: NAVIGATE-HMO (HMO), effective 2024-09-01.
Timely filing	Pass		Received 26 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-026472: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		Authorisation PA2025148408 on file for 43239.
Provider network	Pass		In-network provider Heritage GI Associates (8459983820).
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: Heritage GI Associates2026-01-07 15:19
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-02-02 02:42
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-02-02 10:45
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025148408_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-07 to 2026-04-07.
Itemized billitemized_PA-644643.pdf7 pages
Itemised statement totalling $1939.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-22 12:44
Duplicate check: Exact duplicate of CLM-2026-026472: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-006289	2026-04-04	Mesa GI Associates	$260.00	Approved
CLM-2026-032126	2026-04-06	Desert Diagnostic Imaging	$3,062.00	Needs review
CLM-2026-026472	2026-01-07	Heritage GI Associates	$1,939.00	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