CLM-2026-005855
Meadow GI Associates, Gastroenterology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-03.
Member
Resolved through the identity graph
- Member
- Adam Li
- Member ID
- UHC-03793-43
- Date of birth
- 1945-01-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416778
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0546
- Coverage period
- 2024-05-01 to present
- Deductible
- $276.25 of $1,500.0018%
- Out-of-pocket maximum
- $782.18 of $6,000.0013%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 7380391905
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025498663 / 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 | $2,241.00 | $1,008.45 | $1,008.45 | $0.00 | Paid |
| Totals | $2,241.00 | $1,008.45 | $1,008.45 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-328833
- 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-009443 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-08: - (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025498663 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 Associates2026-01-08 12:09
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025498663_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-328833.pdf3 pages
Itemised statement totalling $2241.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007787 | 2025-12-22 | Canyon Clinical Laboratories | $99.00 | 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.