Claims workbench/CLM-2026-030309

Institutional claim · UB-04 · Provider portal

CLM-2026-030309

Riverside Digestive Health Center, Gastroenterology. Service 2026-03-19 at outpatient hospital (POS 22). Received 2026-04-07.

Needs review

Billed

$1,403.00

1 line

Allowed

$771.65

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

DUP

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Kayla Richards
Member ID: UHC-42568-66
Date of birth: 1976-01-10
Identity: Verified5 records, confidence 0.93
Claim record: CLMCLM-420024
Relationship: Self, Dallas, TX

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-3851
Coverage period: 2021-02-01 to present
Deductible: $1,877.38 of $2,500.0075%
Out-of-pocket maximum: $1,717.31 of $7,500.0023%
Copays: office $40.00, specialist $60.00, emergency $250.00
Physical therapy visits: 6 of 20 used

Provider

Billing and rendering

Billing provider: Riverside Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 8834777772
Network: In network
Rendering NPI: 9600169509
Location: Tempe, AZ · TIN 41-1081863
Authorisation / referral: PA2026708165 / 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	$1,403.00	$771.65	—	—	Review
Totals						$1,403.00	$771.65	—	—

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-483577
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-009104 (verified, link confidence 0.93).
Eligibility	Pass		Active on 2026-03-19: OPTIONS-PPO (PPO), effective 2021-02-01.
Timely filing	Pass		Received 19 days after service (limit 90).
Duplicate check	Review	DUP	Same member, date of service and procedures as CLM-2026-030308, billed by a different provider. Possible duplicate
Prior authorisation	Pass		Authorisation PA2026708165 on file for 43239.
Provider network	Pass		In-network provider Riverside Digestive Health Center (8834777772).
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Riverside Digestive Health Center2026-03-19 15:08
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
SystemSystem: Claims system2026-04-07 02:49
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.

Attachments

Documents received with the claim

Prior auth letterPA2026708165_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-19 to 2026-06-17.
Itemized billitemized_PA-483577.pdf9 pages
Itemised statement totalling $1403.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Duplicate check: Same member, date of service and procedures as CLM-2026-030308, billed by a different provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-030805	2026-07-19	Northgate Medical Group	$150.00	Needs review
CLM-2026-030804	2026-07-19	Evergreen Family Practice	$150.00	Approved
CLM-2026-030308	2026-03-19	Sunrise Digestive Health Center	$1,403.00	Approved
CLM-2026-005072	2025-12-21	Lakeside Medical Group	$310.00	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: Possible duplicate

Different billing provider; separately payable.

Review queue Member identity