CLM-2026-011685
Riverside GI Associates, Gastroenterology. Service 2026-05-16 at outpatient hospital (POS 22). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Billy Green
- Member ID
- UHC-62141-75
- Date of birth
- 1951-07-15
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-402538
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4595
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,357.12 of $3,500.0067%
- Out-of-pocket maximum
- $3,275.33 of $7,000.0047%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 6439808778
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2025549012 / 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 | $1,365.00 | $750.75 | $750.75 | $0.00 | Paid |
| Totals | $1,365.00 | $750.75 | $750.75 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-758518
- 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-006938 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-05-16: NULL (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025549012 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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 GI Associates2026-05-16 16:53
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025549012_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-16 to 2026-08-14.
- Itemized billitemized_PA-758518.pdf4 pages
Itemised statement totalling $1365.00 across 1 line.
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.