CLM-2026-000726
Summit Digestive Health Center, Gastroenterology. Service 2026-04-07 at office (POS 11). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Jason Guerrero
- Member ID
- UHC-14738-35
- Date of birth
- 1949-07-19
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-409875
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3440
- Coverage period
- 2024-07-01 to present
- Deductible
- $14.01 of $500.003%
- Out-of-pocket maximum
- $140.16 of $1,500.009%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 2829648320
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- PA2025327681 / 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 | $271.00 | $168.02 | — | — | Review |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 59 | 1 | 1 | $1,605.00 | $995.10 | — | — | Review |
| Totals | $1,876.00 | $1,163.12 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-334100
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-030670 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-07: OPTIONS-PPO (PPO), effective 2024-07-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025327681 on file for 43239. | |
| Provider network | Pass | In-network provider Summit Digestive Health Center (1126576986). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Summit Digestive Health Center2026-04-07 09:18
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-05-14 01:06
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-14 10:21
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025327681_approval.pdf2 pages
Utilisation management approval letter for 99214 (Office visit, established patient, moderate complexity), valid 2026-04-07 to 2026-07-06.
- Medical recordrecords_PA-334100.pdf7 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (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-2026-031055 | 2026-08-09 | Evergreen Reference Lab | $54.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.