Claims workbench/CLM-2026-027581

Institutional claim · UB-04 · EDI 837I

CLM-2026-027581

Pinecrest GI Associates, Gastroenterology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-08-20.

PendedIdentity on hold: CASE-002028

Billed

$4,544.00

2 lines

Allowed

$2,499.20

if approved

Plan pays

—

Pended

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Pend

IDQ

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Martha Kim
Member ID: none on golden record
Date of birth: 1972-01-20
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-415179
Relationship: Self

Coverage and accumulators

Found by name and date of birth

Plan: CHOICE-PLUS-PPO PPO group GRP-1777
Coverage period: 2024-06-01 to present
Deductible: $1,091.69 of $2,500.0044%
Out-of-pocket maximum: $1,526.11 of $7,500.0020%
Copays: office $20.00, specialist $75.00, emergency $150.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 6204581436
Network: In network
Rendering NPI: 5439286332
Location: Scottsdale, AZ · TIN 29-4594726
Authorisation / referral: PA2026825240 / 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	$2,009.00	$1,104.95	—	—	PendedIDQ
2	45378 rev 0750	Colonoscopy, diagnostic	—	1	2	$2,535.00	$1,394.25	—	—	PendedIDQ
Totals						$4,544.00	$2,499.20	—	—

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-513771
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002028; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Note		Active on 2026-08-09: CHOICE-PLUS-PPO (PPO), effective 2024-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Timely filing	Pass		Received 11 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026825240 on file for 43239, 45378.
Provider network	Pass		In-network provider Pinecrest GI Associates (6204581436).
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: Pended.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest GI Associates2026-08-09 17:27
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

Prior auth letterPA2026825240_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-09 to 2026-11-07.
Itemized billitemized_PA-513771.pdf5 pages
Itemised statement totalling $4544.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules enginePended2026-10-22 12:44
Member identity: Member record is in open steward case CASE-002028; payment withheld until the identity is confirmed. Eligibility: Active on 2026-08-09: CHOICE-PLUS-PPO (PPO), effective 2024-06-01. Coverage found by name and date of birth because the claim carried no usable member ID.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity