CLM-2026-005956
Summit Digestive Health Center, Gastroenterology. Service 2026-03-24 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Sean Nguyen
- Member ID
- UHC-10988-10
- Date of birth
- 2004-05-04
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-417225
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2022-02-01 to present
- Deductible
- $1,071.52 of $3,500.0031%
- Out-of-pocket maximum
- $191.01 of $7,000.003%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 2411028386
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- PA2025752515 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $216.00 | $118.80 | $118.80 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 1,2 | $1,716.00 | $943.80 | $943.80 | $0.00 | Paid |
| Totals | $1,932.00 | $1,062.60 | $1,062.60 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-939165
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018931 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-24: CHOICE-PLUS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025752515 on file for 45378. | |
| Provider network | Pass | In-network provider Summit Digestive Health Center (1126576986). | |
| 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: Summit Digestive Health Center2026-03-24 17:27
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025752515_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-03-24 to 2026-06-22.
- Itemized billitemized_PA-939165.pdf4 pages
Itemised statement totalling $1932.00 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 12:44Clean claim.
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.