CLM-2026-015658
Summit Digestive Health Center, Gastroenterology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-08-20.
Member
Resolved through the identity graph
- Member
- Jason Watson
- Member ID
- UHC-31272-97
- Date of birth
- 1999-06-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-418717
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0936
- Coverage period
- 2022-03-01 to 2026-07-02
- Deductible
- $562.25 of $1,000.0056%
- Out-of-pocket maximum
- $958.71 of $3,000.0032%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 2562010704
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- none / 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 | $275.00 | $151.25 | — | — | DeniedCO27 |
| Totals | $275.00 | $151.25 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-394853
- 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-008031 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-09 is after coverage terminated on 2026-07-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Digestive Health Center (1126576986). | |
| 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: Summit Digestive Health Center2026-07-09 10:31
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-20 04:24
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-20 17:50
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-394853.pdf3 pages
Itemised statement totalling $275.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-09 is after coverage terminated on 2026-07-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029680 | 2026-06-14 | Desert Primary Care Associates | $531.00 | Approved |
| CLM-2026-021368 | 2025-12-25 | Riverside Family Practice | $449.00 | 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
Service after coverage termination.