CLM-2026-011550
Valley Digestive Health Center, Gastroenterology. Service 2026-07-01 at outpatient hospital (POS 22). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Ralph Morales
- Member ID
- UHC-99123-94
- Date of birth
- 1944-05-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-418202
- Relationship
- Spouse, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group N/A
- Coverage period
- 2024-05-01 to present
- Deductible
- $115.24 of $500.0023%
- Out-of-pocket maximum
- $263.58 of $1,000.0026%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 4124259399
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2026602114 / 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 | $261.00 | $143.55 | $143.55 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $2,562.00 | $1,409.10 | $474.79 | $934.31 | Paid |
| Totals | $2,823.00 | $1,552.65 | $618.34 | $934.31 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-682417
- 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-031105 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-01: OPTIONS-PPO (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026602114 on file for 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 Center2026-07-01 14:36
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026602114_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-01 to 2026-09-29.
- Itemized billitemized_PA-682417.pdf3 pages
Itemised statement totalling $2823.00 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.