CLM-2026-016827
Meadow GI Associates, Gastroenterology. Service 2026-05-25 at outpatient hospital (POS 22). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Tyler Taylor
- Member ID
- UHC-19451-27
- Date of birth
- 2000-06-06
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-401773
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6465
- Coverage period
- 2025-02-01 to present
- Deductible
- $296.54 of $1,000.0030%
- Out-of-pocket maximum
- $1,268.51 of $3,000.0042%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1813475971
- Network
- In network
- Rendering NPI
- 6246671732
- Location
- Austin, TX · TIN 38-1568789
- Authorisation / referral
- none / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $248.00 | $136.40 | $136.40 | $0.00 | Paid |
| Totals | $248.00 | $136.40 | $136.40 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-989908
- 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-022322 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-25: MEDICARE-ADV-B (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Meadow GI Associates (1813475971). | |
| 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: Meadow GI Associates2026-05-25 09:27
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-989908.pdf7 pages
Itemised statement totalling $248.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030874 | 2026-06-05 | Summit Internal Medicine Associates | $224.00 | Approved |
| CLM-2026-014821 | 2026-04-08 | Heritage Primary Care Associates | $275.00 | Approved |
| CLM-2026-009552 | 2026-02-22 | Pinecrest Bone and Joint Center | $186.00 | 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.