CLM-2026-011824
Valley Digestive Health Center, Gastroenterology. Service 2026-01-27 at outpatient hospital (POS 22). Received 2026-03-07.
Member
Resolved through the identity graph
- Member
- Willie Mendoza
- Member ID
- UHC-26415-69
- Date of birth
- 1987-03-03
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401430
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0485
- Coverage period
- 2025-07-01 to 2026-07-22
- Deductible
- $2,029.31 of $2,500.0081%
- Out-of-pocket maximum
- $1,891.75 of $10,000.0019%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 9667519547
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2026111593 / 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 | $224.00 | $123.20 | $123.20 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $2,346.00 | $1,290.30 | $630.33 | $659.97 | Paid |
| Totals | $2,570.00 | $1,413.50 | $753.53 | $659.97 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-574109
- 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-015833 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-27: MEDICARE-ADV-B (MA), effective 2025-07-01, terms 2026-07-22. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026111593 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 Center2026-01-27 10:56
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 letterPA2026111593_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-27 to 2026-04-27.
- Itemized billitemized_PA-574109.pdf5 pages
Itemised statement totalling $2570.00 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.