CLM-2026-012629
Riverside Digestive Health Center, Gastroenterology. Service 2026-07-29 at outpatient hospital (POS 22). Received 2026-08-23.
Member
Resolved through the identity graph
- Member
- Donald Griffin
- Member ID
- UHC-74616-95
- Date of birth
- 1954-05-14
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421959
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5276
- Coverage period
- 2025-08-01 to present
- Deductible
- $1,557.55 of $2,500.0062%
- Out-of-pocket maximum
- $654.55 of $7,500.009%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 2600775656
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2025699222 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,338.00 | $1,285.90 | — | — | Review |
| Totals | $2,338.00 | $1,285.90 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-487792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-019432 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-29: MEDICARE-ADV-A (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025699222 on file for 45378. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for encounter for screening for malignant neoplasm of colon. Note dictated; s”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Riverside Digestive Health Center2026-07-29 18:16
Patient seen for encounter for screening for malignant neoplasm of colon. Note dictated; signature pending.
- SystemSystem: Claims system2026-08-23 03:51
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-23 16:52
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025699222_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-29 to 2026-10-27.
- Itemized billitemized_PA-487792.pdf3 pages
Itemised statement totalling $2338.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for encounter for screening for malignant neoplasm of colon. Note dictated; s”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031368 | 2026-10-16 | Mesa Physical Therapy | $240.00 | Approved |
| CLM-2026-017692 | 2026-09-20 | Valley Imaging Center | $701.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.