CLM-2026-008991
Valley Digestive Health Center, Gastroenterology. Service 2026-08-25 at outpatient hospital (POS 22). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Amanda Hicks
- Member ID
- UHC-66518-56
- Date of birth
- 1972-10-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-406864
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2110
- Coverage period
- 2023-07-01 to present
- Deductible
- $1,027.16 of $1,500.0068%
- Out-of-pocket maximum
- $611.79 of $3,000.0020%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 1348410261
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- none / REF471961
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 | $2,498.00 | $1,373.90 | — | — | DeniedCO197 |
| Totals | $2,498.00 | $1,373.90 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-771206
- 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-023476 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-25: CORE-HMO (HMO), effective 2023-07-01. | |
| Timely filing | Pass | Received 31 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 Valley Digestive Health Center (9396653484). | |
| 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: Valley Digestive Health Center2026-08-25 12:36
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-09-25 04:39
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-771206.pdf3 pages
Itemised statement totalling $2498.00 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.