CLM-2026-004830
Meadow GI Associates, Gastroenterology. Service 2025-11-28 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Diego Porter
- Member ID
- UHC-80014-17
- Date of birth
- 1963-11-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-431792
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5209
- Coverage period
- 2022-05-01 to present
- Deductible
- $181.61 of $500.0036%
- Out-of-pocket maximum
- $350.69 of $1,000.0035%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 5526371443
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2026892064 / 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 | $2,076.00 | $934.20 | $441.55 | $492.65 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | 25 | 1 | 2 | $242.00 | $108.90 | $21.78 | $87.12 | Paid |
| Totals | $2,318.00 | $1,043.10 | $463.33 | $579.77 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-608882
- 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-002808 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-28: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026892064 on file for 43239. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow GI Associates2025-11-28 16:40
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026892064_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-11-28 to 2026-02-26.
- Itemized billitemized_PA-608882.pdf8 pages
Itemised statement totalling $2318.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.