CLM-2026-016649
Unity Digestive Health Center, Gastroenterology. Service 2025-12-07 at outpatient hospital (POS 22). Received 2026-07-09.
Member
Resolved through the identity graph
- Member
- Katherine Knight
- Member ID
- UHC-38850-15
- Date of birth
- 2001-03-26
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-404753
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5539
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,757.34 of $3,500.0079%
- Out-of-pocket maximum
- $4,237.88 of $14,000.0030%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7402154927
- Network
- In network
- Rendering NPI
- 5738153530
- Location
- Denver, CO · TIN 51-9644882
- Authorisation / referral
- PA2025163855 / 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 | $2,084.00 | $1,146.20 | — | — | DeniedCO29 |
| Totals | $2,084.00 | $1,146.20 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-718288
- 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-037835 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-07: SELECT-EPO (EPO), effective 2023-11-01. | |
| Timely filing | Fail | CO29 | Received 214 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025163855 on file for 45378. | |
| 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 Center2025-12-07 18:39
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-07-09 00:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-09 11:20
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025163855_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2025-12-07 to 2026-03-07.
- Itemized billitemized_PA-718288.pdf6 pages
Itemised statement totalling $2084.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 214 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.