CLM-2026-012527
Meadow GI Associates, Gastroenterology. Service 2025-12-10 at outpatient hospital (POS 22). Received 2026-01-16.
Member
Resolved through the identity graph
- Member
- Elijah Murphy
- Member ID
- UHC-06509-69
- Date of birth
- 1945-06-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-422445
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5711
- Coverage period
- 2025-02-01 to present
- Deductible
- $812.07 of $1,000.0081%
- Out-of-pocket maximum
- $152.28 of $2,000.008%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1813475971
- Network
- In network
- Rendering NPI
- 4284214556
- Location
- Austin, TX · TIN 38-1568789
- Authorisation / referral
- PA2026576274 / 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 | $1,433.00 | $788.15 | $247.95 | $540.20 | Paid |
| Totals | $1,433.00 | $788.15 | $247.95 | $540.20 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-342096
- 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-005052 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: NULL (PPO), effective 2025-02-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026576274 on file for 43239. | |
| Provider network | Pass | In-network provider Meadow GI Associates (1813475971). | |
| 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: Meadow GI Associates2025-12-10 11:09
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026576274_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-10 to 2026-03-10.
- Itemized billitemized_PA-342096.pdf4 pages
Itemised statement totalling $1433.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015283 | 2026-05-08 | Evergreen Medical Group | $220.00 | Approved |
| CLM-2026-010793 | 2026-01-14 | Lakeside Medical Group | $58.00 | Approved |
| CLM-2026-012528 | 2025-12-10 | Valley Digestive Health Center | $1,433.00 | Needs review |
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.