CLM-2026-007220
Mesa GI Associates, Gastroenterology. Service 2026-04-22 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Susan Garrett
- Member ID
- UHC-86282-68
- Date of birth
- 1939-08-02
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-408941
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4409
- Coverage period
- 2025-05-01 to present
- Deductible
- $362.91 of $2,500.0015%
- Out-of-pocket maximum
- $1,498.91 of $10,000.0015%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7557205672
- Network
- In network
- Rendering NPI
- 5118116487
- Location
- Phoenix, AZ · TIN 12-8480573
- Authorisation / referral
- none / 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 | $340.00 | $187.00 | $187.00 | $0.00 | Paid |
| Totals | $340.00 | $187.00 | $187.00 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-139731
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000426 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-22: CHOICE-PLUS-PPO (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa GI Associates (7557205672). | |
| 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: Mesa GI Associates2026-04-22 15:27
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-139731.pdf8 pages
Itemised statement totalling $340.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025490 | 2026-08-30 | Sunrise Community Hospital | $211.00 | Approved |
| CLM-2026-020984 | 2026-06-06 | Valley Primary Care Associates | $255.00 | Approved |
| CLM-2026-002380 | 2025-12-19 | Mesa Physical Therapy | $164.00 | 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.