CLM-2026-016194
Lakeside Digestive Health Center, Gastroenterology. Service 2026-10-02 at outpatient hospital (POS 22). Received 2026-10-13.
Member
Resolved through the identity graph
- Member
- Carolyn Log
- Member ID
- UHC-35911-04
- Date of birth
- 1953-09-13
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-428519
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group UNKNOWN
- Coverage period
- 2024-10-01 to present
- Deductible
- $765.83 of $1,000.0077%
- Out-of-pocket maximum
- $377.17 of $3,000.0013%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 6263134432
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2025605666 / REF881901
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 | $2,335.00 | $1,284.25 | $549.19 | $735.06 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $243.00 | $133.65 | $40.10 | $93.55 | Paid |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,296.00 | $1,262.80 | $378.84 | $883.96 | Paid |
| Totals | $4,874.00 | $2,680.70 | $968.13 | $1,712.57 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-687670
- 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-023875 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-10-02: CORE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025605666 on file for 43239, 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 Center2026-10-02 18:55
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 letterPA2025605666_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-10-02 to 2026-12-31.
- Itemized billitemized_PA-687670.pdf5 pages
Itemised statement totalling $4874.00 across 3 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-2026-017960 | 2026-03-17 | Northgate Reference Lab | $116.00 | 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.