CLM-2026-012338
Canyon GI Associates, Gastroenterology. Service 2026-07-10 at outpatient hospital (POS 22). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Hiroshi Silva
- Member ID
- UHC-15848-34
- Date of birth
- 1974-10-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424408
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0724
- Coverage period
- 2022-10-01 to 2026-04-15
- Deductible
- $198.24 of $500.0040%
- Out-of-pocket maximum
- $31.66 of $2,000.002%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 5536549897
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2025598165 / 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 | $271.00 | $149.05 | — | — | DeniedCO27 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,070.00 | $1,138.50 | — | — | DeniedCO27 |
| Totals | $2,341.00 | $1,287.55 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-685426
- 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-042353 (provisional, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-10 is after coverage terminated on 2026-04-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025598165 on file for 45378. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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: Canyon GI Associates2026-07-10 14:45
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-08-23 00:00
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-23 17:08
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025598165_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-10 to 2026-10-08.
- Itemized billitemized_PA-685426.pdf3 pages
Itemised statement totalling $2341.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-10 is after coverage terminated on 2026-04-15.
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
Service after coverage termination.