CLM-2026-004321
Riverside Digestive Health Center, Gastroenterology. Service 2026-04-10 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Bobby Santos
- Member ID
- UHC-83369-97
- Date of birth
- 1965-03-28
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-422256
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8950
- Coverage period
- 2024-06-01 to 2026-05-28
- Deductible
- $2,236.99 of $3,500.0064%
- Out-of-pocket maximum
- $272.92 of $10,500.003%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 9421025294
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2026746671 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | 59 | 1 | 1 | $2,150.00 | $1,182.50 | — | — | Review |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 59 | 1 | 1 | $1,787.00 | $982.85 | — | — | Review |
| Totals | $3,937.00 | $2,165.35 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-700691
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029462 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-10: SELECT-EPO (EPO), effective 2024-06-01, terms 2026-05-28. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026746671 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Center2026-04-10 11:56
Patient seen for encounter for screening for malignant neoplasm of colon. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-05-07 05:39
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-07 17:23
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026746671_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-04-10 to 2026-07-09.
- Itemized billitemized_PA-700691.pdf5 pages
Itemised statement totalling $3937.00 across 2 lines.
- Medical recordrecords_PA-700691.pdf7 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008695 | 2026-09-16 | Harbor Regional Medical Center | $1,735.00 | Denied |
| CLM-2026-016260 | 2026-06-06 | Evergreen Family Practice | $659.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.