CLM-2026-002547
Unity Digestive Health Center, Gastroenterology. Service 2026-04-01 at outpatient hospital (POS 22). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Diana Bailey
- Member ID
- UHC-96404-93
- Date of birth
- 1999-10-21
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-417644
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8968
- Coverage period
- 2024-03-01 to present
- Deductible
- $63.90 of $1,500.004%
- Out-of-pocket maximum
- $1,165.08 of $3,000.0039%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7402154927
- Network
- In network
- Rendering NPI
- 1347948501
- Location
- Denver, CO · TIN 51-9644882
- Authorisation / referral
- PA2026393229 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $316.00 | $173.80 | $173.80 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $1,582.00 | $870.10 | $870.10 | $0.00 | Paid |
| Totals | $1,898.00 | $1,043.90 | $1,043.90 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-693116
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011801 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-01: MEDICARE-ADV-B (MA), effective 2024-03-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026393229 on file for 45378. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (7402154927). | |
| 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 Center2026-04-01 12:47
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026393229_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-04-01 to 2026-06-30.
- Itemized billitemized_PA-693116.pdf2 pages
Itemised statement totalling $1898.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009481 | 2026-03-03 | Desert Medical Group | $212.00 | Denied |
| CLM-2026-020902 | 2026-01-30 | Northgate Internal Medicine Associates | $449.00 | Approved |
| CLM-2026-002772 | 2026-01-26 | Mesa Family Practice | $178.00 | Approved |
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.