CLM-2026-001165
Canyon GI Associates, Gastroenterology. Service 2025-12-18 at outpatient hospital (POS 22). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Ann Robertson
- Member ID
- UHC-98509-15
- Date of birth
- 1968-08-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430609
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2404
- Coverage period
- 2023-11-01 to 2026-03-26
- Deductible
- $177.10 of $1,500.0012%
- Out-of-pocket maximum
- $613.37 of $3,000.0020%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 5102606220
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- none / REF964245
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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $340.00 | $187.00 | $187.00 | $0.00 | Paid |
| Totals | $340.00 | $187.00 | $187.00 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-515227
- 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 | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007354 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-18: CORE-HMO (HMO), effective 2023-11-01, terms 2026-03-26. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Canyon GI Associates2025-12-18 16:01
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Itemized billitemized_PA-515227.pdf5 pages
Itemised statement totalling $340.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011108 | 2026-06-18 | Desert Primary Care Associates | $24.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.