CLM-2026-015258
Riverside Digestive Health Center, Gastroenterology. Service 2026-03-02 at outpatient hospital (POS 22). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Jacob Coleman
- Member ID
- UHC-36389-70
- Date of birth
- 1952-08-26
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-429545
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5908
- Coverage period
- 2022-03-01 to present
- Deductible
- $1,325.10 of $1,500.0088%
- Out-of-pocket maximum
- $1,031.90 of $6,000.0017%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 4517153563
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026480788 / 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 | $1,945.00 | $1,069.75 | $443.36 | $626.39 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $1,829.00 | $1,005.95 | $301.79 | $704.16 | Paid |
| Totals | $3,774.00 | $2,075.70 | $745.15 | $1,330.55 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-489312
- 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-007509 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-02: CHOICE-PLUS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026480788 on file for 45378, 43239. | |
| 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 Center2026-03-02 11:37
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026480788_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-03-02 to 2026-05-31.
- Itemized billitemized_PA-489312.pdf9 pages
Itemised statement totalling $3774.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009155 | 2026-08-11 | Harbor Medical Group | $257.00 | Approved |
| CLM-2026-029554 | 2026-02-12 | Mesa Clinical Laboratories | $137.00 | Approved |
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.