Claims workbench/CLM-2026-027011

Institutional claim · UB-04 · EDI 837I

CLM-2026-027011

Meadow GI Associates, Gastroenterology. Service 2026-09-08 at outpatient hospital (POS 22). Received 2026-09-12.

DeniedOut of network

Billed

$1,739.00

2 lines

Allowed

$782.55

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO204

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Nathan Shaw
Member ID: UHC-44338-93
Date of birth: 2003-08-10
Identity: Verified6 records, confidence 0.99
Claim record: CLMCLM-431457
Relationship: Self, Miami, FL

Coverage and accumulators

Found by member ID

Plan: NAVIGATE-HMO HMO group GRP-1416
Coverage period: 2023-02-01 to present
Deductible: $529.26 of $1,500.0035%
Out-of-pocket maximum: $1,261.30 of $4,500.0028%
Copays: office $20.00, specialist $75.00, emergency $250.00
Physical therapy visits: 10 of 20 used

Provider

Billing and rendering

Billing provider: Meadow GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7747243401
Network: Out of network
Rendering NPI: 8863418314
Location: Los Angeles, CA · TIN 16-0400328
Authorisation / referral: PA2026708128 / REF996867

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	59	1	1	$1,428.00	$642.60	—	—	DeniedCO204
2	88305 rev 0310	Surgical pathology, level IV	59	1	1,2	$311.00	$139.95	—	—	DeniedCO204
Totals						$1,739.00	$782.55	—	—

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-914319
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-007486 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-09-08: NAVIGATE-HMO (HMO), effective 2023-02-01.
Timely filing	Pass		Received 4 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026708128 on file for 45378.
Provider network	Fail	CO204	Billing provider 7747243401 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)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
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: Meadow GI Associates2026-09-08 09:32
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-09-12 01:54
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 letterPA2026708128_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-08 to 2026-12-07.
Itemized billitemized_PA-914319.pdf5 pages
Itemised statement totalling $1739.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Provider network: Billing provider 7747243401 is out of network and the HMO plan has no out-of-network benefit. Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-033593	2026-04-07	Sunrise Medical Group	$336.00	Denied
CLM-2026-026977	2026-03-06	Valley Rehabilitation Center	$398.00	Approved
CLM-2026-017331	2026-01-03	Summit Internal Medicine Associates	$383.00	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