CLM-2026-015115
Riverside GI Associates, Gastroenterology. Service 2026-03-20 at outpatient hospital (POS 22). Received 2026-04-02.
Member
Resolved through the identity graph
- Member
- Nicole Ortega
- Member ID
- UHC-19822-22
- Date of birth
- 2005-09-13
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-404816
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-7245
- Coverage period
- 2025-03-01 to present
- Deductible
- $422.91 of $3,500.0012%
- Out-of-pocket maximum
- $1,494.62 of $10,500.0014%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 2766569257
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2025238029 / 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 | $1,571.00 | $864.05 | $864.05 | $0.00 | Paid |
| Totals | $1,571.00 | $864.05 | $864.05 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-659030
- 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-005923 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-20: UNKNOWN (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025238029 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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 GI Associates2026-03-20 15:01
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025238029_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-20 to 2026-06-18.
- Itemized billitemized_PA-659030.pdf2 pages
Itemised statement totalling $1571.00 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
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.