CLM-2026-010369
Unity Digestive Health Center, Gastroenterology. Service 2026-06-12 at outpatient hospital (POS 22). Received 2026-06-19.
Member
Resolved through the identity graph
- Member
- Ryan Bennett
- Member ID
- UHC-03938-67
- Date of birth
- 1983-12-04
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-402964
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group N/A
- Coverage period
- 2024-11-01 to present
- Deductible
- $663.26 of $2,500.0027%
- Out-of-pocket maximum
- $3,443.23 of $10,000.0034%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7402154927
- Network
- In network
- Rendering NPI
- 1498413883
- Location
- Denver, CO · TIN 51-9644882
- Authorisation / referral
- none / 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 | $212.00 | $116.60 | — | — | DeniedCO197 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $2,333.00 | $1,283.15 | — | — | DeniedCO197 |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 1,2 | $1,835.00 | $1,009.25 | — | — | DeniedCO197 |
| Totals | $4,380.00 | $2,409.00 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-244662
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035487 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-12: CORE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239, 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Digestive Health Center (7402154927). | |
| 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: Unity Digestive Health Center2026-06-12 17:53
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-19 03:07
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-244662.pdf4 pages
Itemised statement totalling $4380.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 43239, 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020256 | 2026-05-29 | Mesa Orthopedic Specialists | $37,231.00 | Denied |
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.