CLM-2026-008834
Meadow GI Associates, Gastroenterology. Service 2026-08-29 at outpatient hospital (POS 22). Received 2026-09-17.
Member
Resolved through the identity graph
- Member
- Terry Le
- Member ID
- UHC-29632-13
- Date of birth
- 1982-05-18
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417403
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3264
- Coverage period
- 2024-09-01 to 2026-05-03
- Deductible
- $650.04 of $1,000.0065%
- Out-of-pocket maximum
- $254.73 of $2,000.0013%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 2729704652
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2026490604 / 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 | $1,643.00 | $739.35 | — | — | DeniedCO27 |
| Totals | $1,643.00 | $739.35 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-821995
- 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 | Pass | Attached to MBR-035023 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-29 is after coverage terminated on 2026-05-03. Expenses incurred after coverage terminated |
| 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 PA2026490604 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 Associates2026-08-29 13:15
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-17 01:27
Attachments
Documents received with the claim
- Prior auth letterPA2026490604_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-29 to 2026-11-27.
- Itemized billitemized_PA-821995.pdf2 pages
Itemised statement totalling $1643.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-29 is after coverage terminated on 2026-05-03. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Service after coverage termination.