Claims workbench/CLM-2026-028713

Professional claim · CMS-1500 · EDI 837P

CLM-2026-028713

Heritage Digestive Health Center, Gastroenterology. Service 2026-07-31 at office (POS 11). Received 2026-09-10.

Needs review

Billed

$2,848.00

2 lines

Allowed

$1,765.76

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Lori Hawkins
Member ID: UHC-55156-14
Date of birth: 1990-02-28
Identity: Verified3 records, confidence 0.99
Claim record: CLMCLM-411087
Relationship: Spouse, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan: CHOICE-PLUS-PPO PPO group GRP-7455
Coverage period: 2025-04-01 to present
Deductible: $102.91 of $2,500.004%
Out-of-pocket maximum: $1,945.03 of $10,000.0019%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 15 of 20 used

Provider

Billing and rendering

Billing provider: Heritage Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 4437349366
Network: In network
Rendering NPI: 9035679171
Location: San Diego, CA · TIN 67-1701611
Authorisation / referral: PA2026962547 / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

Line	Code	Description	Mod.	Units	Dx	Billed	Allowed	Member	Plan	Line status
1	99214	Office visit, established patient, moderate complexity	59	1	1	$296.00	$183.52	—	—	Review
2	43239 rev 0750	Upper GI endoscopy with biopsy	59	1	1	$2,552.00	$1,582.24	—	—	Review
Totals						$2,848.00	$1,765.76	—	—

Diagnoses (ICD-10-CM)

1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
2. K58.0 Irritable bowel syndrome with diarrhea

Claim header

Patient account: PA-817137
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-014035 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2026-07-31: NULL (PPO), effective 2025-04-01.
Timely filing	Pass		Received 41 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026962547 on file for 43239.
Provider network	Pass		In-network provider Heritage Digestive Health Center (4437349366).
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Heritage Digestive Health Center2026-07-31 17:32
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-09-10 04:57
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Prior auth letterPA2026962547_approval.pdf2 pages
Utilisation management approval letter for 99214 (Office visit, established patient, moderate complexity), valid 2026-07-31 to 2026-10-29.
Medical recordrecords_PA-817137.pdf15 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
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-2026-023889	2026-05-25	Heritage Primary Care Associates	$232.00	Approved
CLM-2026-003074	2026-01-24	Northgate Reference Lab	$118.00	Denied
CLM-2026-003073	2026-01-24	Northgate Reference Lab	$118.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

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: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity