CLM-2026-005488
Mesa GI Associates, Gastroenterology. Service 2026-06-18 at outpatient hospital (POS 22). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Denise Dunn
- Member ID
- UHC-66614-26
- Date of birth
- 1954-05-11
- Identity
- Verified5 records, confidence 0.94
- Claim record
- CLMCLM-405530
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4923
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,885.30 of $3,500.0054%
- Out-of-pocket maximum
- $4,468.11 of $14,000.0032%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7557205672
- Network
- In network
- Rendering NPI
- 9901191418
- Location
- Phoenix, AZ · TIN 12-8480573
- Authorisation / referral
- PA2025705106 / 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 | — | 1 | 1 | $2,145.00 | $1,179.75 | $1,179.75 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $313.00 | $172.15 | $172.15 | $0.00 | Paid |
| Totals | $2,458.00 | $1,351.90 | $1,351.90 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-250537
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009332 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-06-18: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025705106 on file for 45378. | |
| Provider network | Pass | In-network provider Mesa GI Associates (7557205672). | |
| 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: Mesa GI Associates2026-06-18 15:54
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025705106_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-06-18 to 2026-09-16.
- Itemized billitemized_PA-250537.pdf2 pages
Itemised statement totalling $2458.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019664 | 2026-06-27 | Meadow Imaging Center | $3,584.00 | Needs review |
| CLM-2026-020738 | 2026-03-30 | Canyon Reference Lab | $118.00 | Approved |
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.