CLM-2026-007860
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-02-12 at outpatient hospital (POS 22). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Jennifer Wood
- Member ID
- UHC-28217-72
- Date of birth
- 1995-03-05
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-402991
- Relationship
- Spouse, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0183
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,007.47 of $1,500.0067%
- Out-of-pocket maximum
- $2,291.21 of $6,000.0038%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 6613370363
- Location
- Los Angeles, CA · TIN 73-5559083
- 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,468.00 | $1,357.40 | — | — | DeniedCO197 |
| Totals | $2,468.00 | $1,357.40 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-710504
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016271 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-12: SELECT-EPO (EPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Cornerstone Digestive Health Center (4838407417). | |
| 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: Cornerstone Digestive Health Center2026-02-12 14:41
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-02-27 06:16
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-27 17:24
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-710504.pdf7 pages
Itemised statement totalling $2468.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.