CLM-2026-010522
Riverside Digestive Health Center, Gastroenterology. Service 2025-11-15 at outpatient hospital (POS 22). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Kathy Patel
- Member ID
- UHC-48256-85
- Date of birth
- 1998-03-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409631
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8272
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,576.53 of $3,500.0074%
- Out-of-pocket maximum
- $1,348.54 of $7,000.0019%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 1882564341
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2026856493 / 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 | $183.00 | $100.65 | — | — | DeniedCO29 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,000.00 | $1,100.00 | — | — | DeniedCO29 |
| Totals | $2,183.00 | $1,200.65 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-482063
- 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-034078 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-15: UNKNOWN (PPO), effective 2022-09-01. | |
| Timely filing | Fail | CO29 | Received 205 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026856493 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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: Riverside Digestive Health Center2025-11-15 14:17
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-08 02:29
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026856493_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2025-11-15 to 2026-02-13.
- Itemized billitemized_PA-482063.pdf5 pages
Itemised statement totalling $2183.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 205 days after the last date of service (limit 90).
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
Received after the timely-filing limit.