CLM-2026-016632
Valley Digestive Health Center, Gastroenterology. Service 2026-08-29 at outpatient hospital (POS 22). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Jason Phillips
- Member ID
- UHC-16875-64
- Date of birth
- 1986-08-11
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-413600
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7944
- Coverage period
- 2025-01-01 to present
- Deductible
- $832.60 of $1,500.0056%
- Out-of-pocket maximum
- $230.99 of $4,500.005%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 5019045975
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2025460327 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,849.00 | $1,016.95 | $772.27 | $244.68 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,589.00 | $873.95 | $262.19 | $611.76 | Paid |
| Totals | $3,438.00 | $1,890.90 | $1,034.46 | $856.44 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-371516
- 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-004024 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-29: CHOICE-PLUS-PPO (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025460327 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Valley Digestive Health Center (9396653484). | |
| 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: Valley Digestive Health Center2026-08-29 18:19
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025460327_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-29 to 2026-11-27.
- Itemized billitemized_PA-371516.pdf8 pages
Itemised statement totalling $3438.00 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-2026-013825 | 2026-09-18 | Evergreen Internal Medicine Associates | $646.00 | Approved |
| CLM-2026-012584 | 2026-01-13 | Evergreen Family Practice | $277.00 | Approved |
| CLM-2026-002097 | 2025-11-29 | Harbor Family Practice | $3,506.00 | 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.