CLM-2026-006700
Riverside Digestive Health Center, Gastroenterology. Service 2026-09-11 at outpatient hospital (POS 22). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Amber Wells
- Member ID
- UHC-31236-97
- Date of birth
- 1979-06-25
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-400071
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-9279
- Coverage period
- 2025-03-01 to present
- Deductible
- $514.50 of $1,000.0051%
- Out-of-pocket maximum
- $1,380.46 of $4,000.0035%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 5680523615
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2025835933 / 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 | $2,351.00 | $1,293.05 | $566.26 | $726.79 | Paid |
| Totals | $2,351.00 | $1,293.05 | $566.26 | $726.79 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-344432
- 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-032224 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-11: N/A (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025835933 on file for 45378. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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: Riverside Digestive Health Center2026-09-11 17:22
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025835933_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-11 to 2026-12-10.
- Itemized billitemized_PA-344432.pdf8 pages
Itemised statement totalling $2351.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016245 | 2026-05-31 | Pinecrest Bone and Joint Center | $163.00 | Denied |
| CLM-2026-016244 | 2026-05-31 | Pinecrest Bone and Joint Center | $163.00 | 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.