CLM-2026-003164
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-09-13 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Nancy Wong
- Member ID
- UHC-74984-66
- Date of birth
- 2006-05-23
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-421866
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9306
- Coverage period
- 2025-12-01 to present
- Deductible
- $581.46 of $1,500.0039%
- Out-of-pocket maximum
- $1,288.81 of $3,000.0043%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 1817980141
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- none / 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 | $222.00 | $122.10 | — | — | DeniedCO197 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,629.00 | $1,445.95 | — | — | DeniedCO197 |
| Totals | $2,851.00 | $1,568.05 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-755465
- 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-014859 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-13: OPTIONS-PPO (PPO), effective 2025-12-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Cornerstone Digestive Health Center (4838407417). | |
| 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: Cornerstone Digestive Health Center2026-09-13 13:25
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-18 06:54
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-18 17:01
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-755465.pdf6 pages
Itemised statement totalling $2851.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.