CLM-2026-003687
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-04-24 at outpatient hospital (POS 22). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Lawrence Scott
- Member ID
- UHC-71983-42
- Date of birth
- 1993-10-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-431861
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8171
- Coverage period
- 2021-07-01 to 2026-04-05
- Deductible
- $1,121.27 of $2,500.0045%
- Out-of-pocket maximum
- $376.72 of $7,500.005%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 5403071785
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- PA2025153825 / 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 | $1,389.00 | $763.95 | — | — | DeniedCO27 |
| Totals | $1,389.00 | $763.95 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-976711
- 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-002252 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-24 is after coverage terminated on 2026-04-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025153825 on file for 43239. | |
| 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 Center2026-04-24 17:52
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-05-22 03:03
Attachments
Documents received with the claim
- Prior auth letterPA2025153825_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-04-24 to 2026-07-23.
- Itemized billitemized_PA-976711.pdf5 pages
Itemised statement totalling $1389.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-24 is after coverage terminated on 2026-04-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014561 | 2025-12-12 | Mesa Dermatology Clinic | $203.00 | 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
Service after coverage termination.