Claims workbench/CLM-2026-032698

Institutional claim · UB-04 · EDI 837I

CLM-2026-032698

Sunrise Digestive Health Center, Gastroenterology. Service 2026-05-02 at outpatient hospital (POS 22). Received 2026-05-11.

Denied

Billed

$3,629.00

2 lines

Allowed

$1,995.95

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Ashley Walker
Member ID: UHC-94810-45
Date of birth: 1952-12-07
Identity: Verified4 records, confidence 1.00
Claim record: CLMCLM-420754
Relationship: Spouse, Atlanta, GA

Coverage and accumulators

Found by member ID

Plan: OPTIONS-PPO PPO group GRP-9026
Coverage period: 2022-10-01 to 2026-01-23
Deductible: $328.29 of $1,000.0033%
Out-of-pocket maximum: $1,053.93 of $4,000.0026%
Copays: office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits: 20 of 20 used

Provider

Billing and rendering

Billing provider: Sunrise Digestive Health Center
Gastroenterology · taxonomy 207RG0100X
NPI: 3482505971
Network: In network
Rendering NPI: 9386826801
Location: Los Angeles, CA · TIN 56-5803475
Authorisation / referral: PA2025000223 / 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	59	1	1	$2,031.00	$1,117.05	—	—	DeniedCO27
2	45378 rev 0750	Colonoscopy, diagnostic	59	1	1,2	$1,598.00	$878.90	—	—	DeniedCO27
Totals						$3,629.00	$1,995.95	—	—

Diagnoses (ICD-10-CM)

1. R10.13 Epigastric painprincipal
2. Z12.11 Encounter for screening for malignant neoplasm of colon

Claim header

Patient account: PA-687193
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-012508 (verified, link confidence 1.00).
Eligibility	Fail	CO27	Date of service 2026-05-02 is after coverage terminated on 2026-01-23. Expenses incurred after coverage terminated
Timely filing	Pass		Received 9 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025000223 on file for 43239, 45378.
Provider network	Pass		In-network provider Sunrise Digestive Health Center (3482505971).
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: Sunrise Digestive Health Center2026-05-02 09:40
Follow-up for epigastric pain. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-05-11 02:12
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-11 09:20
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2025000223_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-02 to 2026-07-31.
Itemized billitemized_PA-687193.pdf5 pages
Itemised statement totalling $3629.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Eligibility: Date of service 2026-05-02 is after coverage terminated on 2026-01-23. 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

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

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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity