CLM-2026-008321
Lakeside Digestive Health Center, Gastroenterology. Service 2025-12-23 at outpatient hospital (POS 22). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Nathan Delgado
- Member ID
- none on golden record
- Date of birth
- 1947-12-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-401068
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-3262
- Coverage period
- 2024-04-01 to present
- Deductible
- $435.81 of $1,500.0029%
- Out-of-pocket maximum
- $1,729.99 of $4,500.0038%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 4374352381
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2026841126 / 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 | $1,363.00 | $749.65 | — | — | PendedIDQ |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $195.00 | $107.25 | — | — | PendedIDQ |
| Totals | $1,558.00 | $856.90 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-938021
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000991; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-23: SELECT-EPO (EPO), effective 2024-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026841126 on file for 43239. | |
| Provider network | Pass | In-network provider Lakeside Digestive Health Center (5154884873). | |
| 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: Lakeside Digestive Health Center2025-12-23 11:57
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026841126_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-23 to 2026-03-23.
- Itemized billitemized_PA-938021.pdf5 pages
Itemised statement totalling $1558.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000991; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-23: SELECT-EPO (EPO), effective 2024-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.