CLM-2026-007189
Riverside GI Associates, Gastroenterology. Service 2026-08-19 at outpatient hospital (POS 22). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Evelny Hart
- Member ID
- UHC-67231-57
- Date of birth
- 2002-11-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-419796
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4331
- Coverage period
- 2024-12-01 to present
- Deductible
- $561.68 of $2,500.0022%
- Out-of-pocket maximum
- $4,127.37 of $10,000.0041%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 1258326630
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2026578180 / 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 | $330.00 | $181.50 | $181.50 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $1,595.00 | $877.25 | $877.25 | $0.00 | Paid |
| Totals | $1,925.00 | $1,058.75 | $1,058.75 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-266196
- 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-037808 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-19: NULL (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026578180 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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 GI Associates2026-08-19 09:20
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026578180_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-08-19 to 2026-11-17.
- Itemized billitemized_PA-266196.pdf5 pages
Itemised statement totalling $1925.00 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.