CLM-2026-006451
Meadow GI Associates, Gastroenterology. Service 2026-09-19 at outpatient hospital (POS 22). Received 2026-09-28.
Member
Resolved through the identity graph
- Member
- Nathan Tran
- Member ID
- UHC-26240-33
- Date of birth
- 2003-06-21
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420620
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2535
- Coverage period
- 2025-04-01 to present
- Deductible
- $138.35 of $1,000.0014%
- Out-of-pocket maximum
- $640.12 of $3,000.0021%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 9168095351
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025839782 / 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 | $2,766.00 | $1,244.70 | — | — | Review |
| Totals | $2,766.00 | $1,244.70 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-110943
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-013724 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-19: MEDICARE-ADV-B (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-006450; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | Authorisation PA2025839782 on file for 45378. | |
| 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 Associates2026-09-19 12:21
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-09-28 05:08
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
Attachments
Documents received with the claim
- Prior auth letterPA2025839782_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-19 to 2026-12-18.
- Itemized billitemized_PA-110943.pdf6 pages
Itemised statement totalling $2766.00 across 1 line.
- Corrected claimcorrected_CLM-2026-006450.pdf1 page
Provider cover letter requesting replacement of CLM-2026-006450.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-006450; the original must be voided when this adjudicates. Provider 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-2026-006450 | 2026-09-19 | Meadow GI Associates | $2,766.00 | Approved |
| CLM-2026-006569 | 2026-08-10 | Sunrise Imaging Center | $4,256.00 | Approved |
| CLM-2026-031566 | 2026-06-01 | Valley Digestive Health Center | $2,758.00 | Needs review |
| CLM-2026-025238 | 2026-02-24 | Heritage Primary Care Associates | $224.00 | Approved |
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
Replacement claim supersedes the original.