CLM-2026-015285
Lakeside Digestive Health Center, Gastroenterology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-03-29.
Member
Resolved through the identity graph
- Member
- Paul Carter
- Member ID
- UHC-29814-31
- Date of birth
- 1946-03-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-424521
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0579
- Coverage period
- 2025-08-01 to present
- Deductible
- $838.26 of $1,000.0084%
- Out-of-pocket maximum
- $403.85 of $2,000.0020%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 3483438693
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2026037567 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $241.00 | $132.55 | — | — | DeniedCO29 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $2,582.00 | $1,420.10 | — | — | DeniedCO29 |
| Totals | $2,823.00 | $1,552.65 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-104614
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015034 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Fail | CO29 | Received 104 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026037567 on file for 45378. | |
| Provider network | Pass | In-network provider Lakeside Digestive Health Center (5154884873). | |
| 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: Lakeside Digestive Health Center2025-12-15 12:02
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-29 01:02
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026037567_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2025-12-15 to 2026-03-15.
- Itemized billitemized_PA-104614.pdf8 pages
Itemised statement totalling $2823.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 104 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011647 | 2026-02-01 | Unity Reference Lab | $63.00 | Approved |
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
Received after the timely-filing limit.