CLM-2026-006637
Evergreen Digestive Health Center, Gastroenterology. Service 2026-02-09 at outpatient hospital (POS 22). Received 2026-02-19.
Member
Resolved through the identity graph
- Member
- Gloria Walsh
- Member ID
- UHC-28637-03
- Date of birth
- 1990-11-03
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-411022
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group UNKNOWN
- Coverage period
- 2021-09-01 to present
- Deductible
- $102.58 of $500.0021%
- Out-of-pocket maximum
- $335.45 of $1,500.0022%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 8497488550
- Location
- San Diego, CA · TIN 71-8732123
- Authorisation / referral
- PA2026135140 / REF232573
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 | $2,455.00 | $1,350.25 | $587.99 | $762.26 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $268.00 | $147.40 | $29.48 | $117.92 | Paid |
| Totals | $2,723.00 | $1,497.65 | $617.47 | $880.18 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-607776
- 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-014230 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-09: NAVIGATE-HMO (HMO), effective 2021-09-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026135140 on file for 45378. | |
| Provider network | Pass | In-network provider Evergreen Digestive Health Center (7438481310). | |
| 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: Evergreen Digestive Health Center2026-02-09 11:59
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026135140_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-09 to 2026-05-10.
- Itemized billitemized_PA-607776.pdf7 pages
Itemised statement totalling $2723.00 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.