Claims workbench/CLM-2026-026979

Institutional claim · UB-04 · EDI 837I

CLM-2026-026979

Evergreen GI Associates, Gastroenterology. Service 2026-04-15 at outpatient hospital (POS 22). Received 2026-07-24.

Denied

Billed

$3,109.00

2 lines

Allowed

$1,709.95

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 20% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Eric Sullivan
Member ID: UHC-21997-61
Date of birth: 1963-09-08
Identity: Verified5 records, confidence 0.99
Claim record: CLMCLM-413624
Relationship: Spouse, Sacramento, CA

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-2586
Coverage period: 2021-12-01 to present
Deductible: $210.86 of $1,000.0021%
Out-of-pocket maximum: $489.08 of $2,000.0024%
Copays: office $20.00, specialist $60.00, emergency $250.00
Physical therapy visits: 7 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 1347472536
Network: In network
Rendering NPI: 3897380515
Location: Mesa, AZ · TIN 73-5641725
Authorisation / referral: PA2026793977 / 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	88305 rev 0310	Surgical pathology, level IV	—	1	1	$352.00	$193.60	—	—	DeniedCO29
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	2	$2,757.00	$1,516.35	—	—	DeniedCO29
Totals						$3,109.00	$1,709.95	—	—

Diagnoses (ICD-10-CM)

1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-422821
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-010955 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-04-15: NULL (PPO), effective 2021-12-01.
Timely filing	Fail	CO29	Received 100 days after the last date of service (limit 90). Time limit for filing has expired
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026793977 on file for 45378.
Provider network	Pass		In-network provider Evergreen GI Associates (1347472536).
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: Evergreen GI Associates2026-04-15 17:02
Patient seen for encounter for screening for malignant neoplasm of colon.
SystemSystem: Claims system2026-07-24 02:58
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-24 11:25
Reviewed with the member's history on file. Holding for the items listed above.

Attachments

Documents received with the claim

Prior auth letterPA2026793977_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-04-15 to 2026-07-14.
Itemized billitemized_PA-422821.pdf8 pages
Itemised statement totalling $3109.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 100 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-003054	2026-07-08	Desert Internal Medicine Associates	$492.00	Approved
CLM-2026-000279	2026-06-18	Sunrise Orthopedic Specialists	$181.00	Approved
CLM-2026-011103	2026-04-30	Canyon Medical Group	$190.00	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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity