Claims workbench/CLM-2026-027661

Institutional claim · UB-04 · EDI 837I

CLM-2026-027661

Riverside GI Associates, Gastroenterology. Service 2026-06-27 at outpatient hospital (POS 22). Received 2026-07-26.

Approved

Billed

$1,779.00

2 lines

Allowed

$978.45

contract rate applied

Plan pays

$448.35

approved

Member owes

$530.10

copay / deductible / 10% coinsurance

Rules engine

Clean

no reason codes

Decided by

Claims rules engine

2026-10-22 12:44

Member

Resolved through the identity graph

Member: Amber Ortega
Member ID: UHC-28858-52
Date of birth: 1979-12-23
Identity: Verified3 records, confidence 1.00
Claim record: CLMCLM-417482
Relationship: Spouse, Houston, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-2249
Coverage period: 2023-02-01 to present
Deductible: $1,019.72 of $1,500.0068%
Out-of-pocket maximum: $843.57 of $4,500.0019%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 4 of 20 used

Provider

Billing and rendering

Billing provider: Riverside GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI: 7858029219
Network: In network
Rendering NPI: 8612444447
Location: San Diego, CA · TIN 69-3440792
Authorisation / referral: PA2026545777 / 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	$1,542.00	$848.10	$517.06	$331.04	Paid
2	88305 rev 0310	Surgical pathology, level IV	—	1	1	$237.00	$130.35	$13.04	$117.31	Paid
Totals						$1,779.00	$978.45	$530.10	$448.35

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. R10.13 Epigastric pain

Claim header

Patient account: PA-934344
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 0 needing attention

Check	Result	Detail
Member identity	Pass	Attached to MBR-011475 (verified, link confidence 1.00).
Eligibility	Pass	Active on 2026-06-27: OPTIONS-PPO (PPO), effective 2023-02-01.
Timely filing	Pass	Received 29 days after service (limit 90).
Duplicate check	Pass	No matching prior claim in the duplicate window.
Prior authorisation	Pass	Authorisation PA2026545777 on file for 43239.
Provider network	Pass	In-network provider Riverside GI Associates (7858029219).
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. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside GI Associates2026-06-27 12:48
Patient seen for gastro-esophageal reflux disease without esophagitis.

Attachments

Documents received with the claim

Prior auth letterPA2026545777_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-06-27 to 2026-09-25.
Itemized billitemized_PA-934344.pdf2 pages
Itemised statement totalling $1779.00 across 2 lines.

Explanation of benefits

What the member will see

Amount billed

$1,779.00

Plan discount

$800.55

contracted rate

Plan paid

$448.35

You may owe

$530.10

copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

Rules engineApproved2026-10-22 12:44
Clean claim.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005812	2026-01-30	Desert Clinical Laboratories	$100.00	Approved

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved 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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue Member identity