CLM-2026-010739
Valley Digestive Health Center, Gastroenterology. Service 2026-02-21 at outpatient hospital (POS 22). Received 2026-03-14.
Member
Resolved through the identity graph
- Member
- John Young
- Member ID
- UHC-87848-29
- Date of birth
- 1955-02-28
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-402967
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6165
- Coverage period
- 2025-04-01 to present
- Deductible
- $669.81 of $1,000.0067%
- Out-of-pocket maximum
- $1,057.88 of $3,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 8853953536
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2025542313 / 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 | $2,369.00 | $1,302.95 | $427.47 | $875.48 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,454.00 | $799.70 | $79.97 | $719.73 | Paid |
| Totals | $3,823.00 | $2,102.65 | $507.44 | $1,595.21 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-695006
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019550 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-21: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025542313 on file for 45378, 43239. | |
| 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 Center2026-02-21 15:19
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025542313_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-21 to 2026-05-22.
- Itemized billitemized_PA-695006.pdf4 pages
Itemised statement totalling $3823.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.