CLM-2026-008647
Canyon GI Associates, Gastroenterology. Service 2026-09-10 at outpatient hospital (POS 22). Received 2026-09-26.
Member
Resolved through the identity graph
- Member
- Jennifer Schmidt
- Member ID
- UHC-32919-73
- Date of birth
- 1952-01-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-403986
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group N/A
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,063.14 of $3,500.0030%
- Out-of-pocket maximum
- $3,945.41 of $10,500.0038%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 8352727142
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2026631829 / 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 | $253.00 | $139.15 | $139.15 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 1,2 | $1,485.00 | $816.75 | $816.75 | $0.00 | Paid |
| 3 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $2,344.00 | $1,289.20 | $1,289.20 | $0.00 | Paid |
| Totals | $4,082.00 | $2,245.10 | $2,245.10 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-652836
- 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-028449 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-10: NULL (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026631829 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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: Canyon GI Associates2026-09-10 09:23
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026631829_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-09-10 to 2026-12-09.
- Itemized billitemized_PA-652836.pdf3 pages
Itemised statement totalling $4082.00 across 3 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.