CLM-2026-003518
Riverside Digestive Health Center, Gastroenterology. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Charles Dunn
- Member ID
- UHC-26801-85
- Date of birth
- 1993-10-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410904
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8129
- Coverage period
- 2025-05-01 to present
- Deductible
- $529.50 of $1,000.0053%
- Out-of-pocket maximum
- $515.82 of $4,000.0013%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 9222872399
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2025690870 / 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 | $2,401.00 | $1,320.55 | — | — | DeniedCO18 |
| Totals | $2,401.00 | $1,320.55 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-773126
- 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-025965 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-16: OPTIONS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003517: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025690870 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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 Digestive Health Center2026-06-16 12:53
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-14 06:08
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025690870_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-06-16 to 2026-09-14.
- Itemized billitemized_PA-773126.pdf9 pages
Itemised statement totalling $2401.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-003517: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003517 | 2026-06-16 | Riverside Digestive Health Center | $2,401.00 | Approved |
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
Exact duplicate of an earlier submission.