CLM-2026-013501
Riverside Digestive Health Center, Gastroenterology. Service 2026-09-15 at outpatient hospital (POS 22). Received 2026-09-20.
Member
Resolved through the identity graph
- Member
- Arjun Lopez
- Member ID
- UHC-85521-93
- Date of birth
- 1959-11-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404939
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9325
- Coverage period
- 2023-08-01 to present
- Deductible
- $2,130.34 of $2,500.0085%
- Out-of-pocket maximum
- $3,680.84 of $7,500.0049%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 3906264379
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- none / REF131939
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 | $1,687.00 | $927.85 | — | — | DeniedCO197 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,156.00 | $1,185.80 | — | — | DeniedCO197 |
| Totals | $3,843.00 | $2,113.65 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-841127
- 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-044602 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-15: CORE-HMO (HMO), effective 2023-08-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239, 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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: Riverside Digestive Health Center2026-09-15 13:44
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-20 04:06
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-20 08:57
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-841127.pdf2 pages
Itemised statement totalling $3843.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239, 45378 require precertification; no authorisation number on the claim.
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
Precertification required and absent.