CLM-2026-012598
Unity Digestive Health Center, Gastroenterology. Service 2026-05-28 at outpatient hospital (POS 22). Received 2026-07-11.
Member
Resolved through the identity graph
- Member
- Maria Vazquez
- Member ID
- UHC-60301-52
- Date of birth
- 1954-10-10
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-415498
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7124
- Coverage period
- 2025-10-01 to present
- Deductible
- $621.45 of $3,500.0018%
- Out-of-pocket maximum
- $1,383.98 of $14,000.0010%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 4939106843
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PA2025099374 / 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 | $1,969.00 | $1,082.95 | $1,082.95 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 1 | $2,001.00 | $1,100.55 | $1,100.55 | $0.00 | Paid |
| Totals | $3,970.00 | $2,183.50 | $2,183.50 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-706513
- 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-038083 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-28: SELECT-EPO (EPO), effective 2025-10-01. | |
| 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 PA2025099374 on file for 43239, 45378. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-05-28 10:31
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Prior auth letterPA2025099374_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-28 to 2026-08-26.
- Itemized billitemized_PA-706513.pdf8 pages
Itemised statement totalling $3970.00 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.