CLM-2026-002187
Unity Digestive Health Center, Gastroenterology. Service 2026-02-28 at outpatient hospital (POS 22). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- James Hanson
- Member ID
- UHC-90765-54
- Date of birth
- 1984-11-23
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-422273
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0887
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,886.66 of $2,500.0075%
- Out-of-pocket maximum
- $669.15 of $10,000.007%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 4512866441
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PHONE-605572 / 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 | $1,736.00 | $954.80 | — | — | Review |
| Totals | $1,736.00 | $954.80 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-502227
- 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-005594 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-28: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-605572” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-02-28 13:33
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-04-11 04:15
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-502227.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-502227.pdf7 pages
Itemised statement totalling $1736.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-605572” does not match the utilisation-management format; must be confirmed before payment.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010142 | 2026-08-26 | Riverside Primary Care Associates | $253.00 | Needs review |
| CLM-2026-010141 | 2026-08-26 | Riverside Primary Care Associates | $253.00 | Approved |
| CLM-2026-025406 | 2026-06-13 | Northgate Reference Lab | $75.00 | Approved |
| CLM-2026-002793 | 2026-04-22 | Northgate Internal Medicine Associates | $375.00 | Approved |
| CLM-2026-015207 | 2026-05-16 | Meadow Heart Institute | $925.00 | 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
Authorisation must be confirmed with UM before payment.