CLM-2026-016870
Valley Digestive Health Center, Gastroenterology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Rachel Green
- Member ID
- UHC-78943-88
- Date of birth
- 1972-10-06
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-419003
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6302
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,233.58 of $1,500.0082%
- Out-of-pocket maximum
- $2,657.70 of $6,000.0044%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 4947838106
- Location
- Los Angeles, CA · TIN 94-4926360
- 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 | $259.00 | $142.45 | — | — | DeniedCO18 |
| Totals | $259.00 | $142.45 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-519088
- 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-025662 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-14: N/A (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016869: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-06-14 11:17
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-07-26 00:41
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-26 08:07
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-519088.pdf7 pages
Itemised statement totalling $259.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-016869: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016869 | 2026-06-14 | Valley Digestive Health Center | $259.00 | Approved |
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
Exact duplicate of an earlier submission.