CLM-2026-016079
Unity Digestive Health Center, Gastroenterology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Doris Murphy
- Member ID
- UHC-18676-02
- Date of birth
- 1953-03-22
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-407492
- Relationship
- Spouse, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1535
- Coverage period
- 2021-02-01 to present
- Deductible
- $2,547.20 of $3,500.0073%
- Out-of-pocket maximum
- $4,987.35 of $14,000.0036%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 4558343693
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PA2025827023 / REF262998
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 | $1,487.00 | $817.85 | $817.85 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $287.00 | $157.85 | $137.24 | $20.61 | Paid |
| Totals | $1,774.00 | $975.70 | $955.09 | $20.61 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-113576
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004612 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-01-08: NAVIGATE-HMO (HMO), effective 2021-02-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025827023 on file for 45378. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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 Center2026-01-08 18:27
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025827023_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-113576.pdf3 pages
Itemised statement totalling $1774.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029726 | 2026-03-05 | Canyon Reference Lab | $111.00 | Needs review |
| CLM-2026-029725 | 2026-03-05 | Canyon Reference Lab | $111.00 | Approved |
| CLM-2026-025705 | 2026-01-05 | Evergreen Family Practice | $233.00 | 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.