CLM-2026-016047
Unity Digestive Health Center, Gastroenterology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Peter Phillips
- Member ID
- UHC-99427-19
- Date of birth
- 1986-09-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423094
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3295
- Coverage period
- 2021-02-01 to present
- Deductible
- $299.31 of $500.0060%
- Out-of-pocket maximum
- $62.60 of $2,000.003%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7402154927
- Network
- In network
- Rendering NPI
- 9778763679
- Location
- Denver, CO · TIN 51-9644882
- Authorisation / referral
- PA2026954674 / 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 | $2,082.00 | $1,145.10 | $484.01 | $661.09 | Paid |
| Totals | $2,082.00 | $1,145.10 | $484.01 | $661.09 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-604195
- 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-003319 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-22: OPTIONS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026954674 on file for 43239. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (7402154927). | |
| 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: Unity Digestive Health Center2026-08-22 18:48
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026954674_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-22 to 2026-11-20.
- Itemized billitemized_PA-604195.pdf9 pages
Itemised statement totalling $2082.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016048 | 2026-08-22 | Meadow GI Associates | $2,082.00 | Needs review |
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.