CLM-2026-017426
Riverside Digestive Health Center, Gastroenterology. Service 2026-08-28 at outpatient hospital (POS 22). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Priya Fuller
- Member ID
- UHC-15580-09
- Date of birth
- 1951-07-13
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-430054
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group NULL
- Coverage period
- 2021-03-01 to present
- Deductible
- $999.81 of $3,500.0029%
- Out-of-pocket maximum
- $5,145.06 of $14,000.0037%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 6874623559
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026021276 / 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 | $2,275.00 | $1,251.25 | $1,251.25 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $1,912.00 | $1,051.60 | $1,051.60 | $0.00 | Paid |
| Totals | $4,187.00 | $2,302.85 | $2,302.85 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-879497
- 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-028713 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-28: CHOICE-PLUS-PPO (PPO), effective 2021-03-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026021276 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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: Riverside Digestive Health Center2026-08-28 11:12
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Prior auth letterPA2026021276_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-28 to 2026-11-26.
- Itemized billitemized_PA-879497.pdf4 pages
Itemised statement totalling $4187.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031182 | 2026-05-03 | Meadow Cardiovascular Associates | $685.00 | 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.