CLM-2026-003187
Riverside GI Associates, Gastroenterology. Service 2026-04-25 at outpatient hospital (POS 22). Received 2026-09-08.
Member
Resolved through the identity graph
- Member
- Emily Thompson
- Member ID
- UHC-60492-22
- Date of birth
- 1964-02-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-411752
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0562
- Coverage period
- 2021-03-01 to present
- Deductible
- $345.33 of $500.0069%
- Out-of-pocket maximum
- $94.00 of $1,500.006%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 7873086350
- Location
- San Diego, CA · TIN 69-3440792
- 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 | $317.00 | $174.35 | — | — | DeniedCO29 |
| Totals | $317.00 | $174.35 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-721992
- 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-014372 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-25: SELECT-EPO (EPO), effective 2021-03-01. | |
| Timely filing | Fail | CO29 | Received 136 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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: Riverside GI Associates2026-04-25 17:10
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-08 01:45
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-08 15:22
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-721992.pdf2 pages
Itemised statement totalling $317.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 136 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009726 | 2026-09-05 | Unity Diagnostic Imaging | $2,386.00 | Approved |
| CLM-2026-004006 | 2026-02-15 | Pinecrest Diagnostic Imaging | $2,481.00 | Needs review |
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
Received after the timely-filing limit.