CLM-2026-008571
Meadow GI Associates, Gastroenterology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Wayne Garza
- Member ID
- UHC-17167-67
- Date of birth
- 1990-11-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417734
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1066
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,483.11 of $3,500.0042%
- Out-of-pocket maximum
- $1,134.29 of $7,000.0016%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 7210328408
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025906415 / 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 | $2,514.00 | $1,131.30 | $1,131.30 | $0.00 | Paid |
| Totals | $2,514.00 | $1,131.30 | $1,131.30 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-458798
- 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-002008 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-02: MEDICARE-ADV-A (MA), effective 2023-01-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025906415 on file for 45378. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow GI Associates2026-01-02 15:05
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025906415_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-01-02 to 2026-04-02.
- Itemized billitemized_PA-458798.pdf6 pages
Itemised statement totalling $2514.00 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003099 | 2026-10-15 | Evergreen GI Associates | $289.00 | Needs review |
| CLM-2026-003098 | 2026-10-15 | Evergreen GI Associates | $289.00 | 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.