CLM-2026-009112
Summit Digestive Health Center, Gastroenterology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Terry Turner
- Member ID
- UHC-21752-21
- Date of birth
- 1971-11-01
- Identity
- Verified2 records, confidence 0.94
- Claim record
- CLMCLM-422737
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1067
- Coverage period
- 2025-08-01 to 2026-01-01
- Deductible
- $2,463.64 of $3,500.0070%
- Out-of-pocket maximum
- $2,507.89 of $7,000.0036%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 6877825342
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- PA2026909234 / 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 | $2,552.00 | $1,403.60 | — | — | DeniedCO27 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $322.00 | $177.10 | — | — | DeniedCO27 |
| Totals | $2,874.00 | $1,580.70 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-324483
- 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-036289 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-24 is after coverage terminated on 2026-01-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026909234 on file for 43239. | |
| Provider network | Pass | In-network provider Summit Digestive Health Center (1126576986). | |
| 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: Summit Digestive Health Center2026-07-24 17:52
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-02 03:04
Attachments
Documents received with the claim
- Prior auth letterPA2026909234_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-07-24 to 2026-10-22.
- Itemized billitemized_PA-324483.pdf8 pages
Itemised statement totalling $2874.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-24 is after coverage terminated on 2026-01-01.
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.