CLM-2026-017898
Valley Digestive Health Center, Gastroenterology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Gary Burton
- Member ID
- UHC-41264-81
- Date of birth
- 1988-01-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-404877
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4384
- Coverage period
- 2022-07-01 to present
- Deductible
- $262.81 of $1,000.0026%
- Out-of-pocket maximum
- $1,998.32 of $4,000.0050%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 4462288471
- 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 | $286.00 | $157.30 | $157.30 | $0.00 | Paid |
| Totals | $286.00 | $157.30 | $157.30 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-686098
- 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-001487 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: NAVIGATE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 5 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 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 Center2025-12-31 18:50
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-686098.pdf8 pages
Itemised statement totalling $286.00 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-2026-023600 | 2026-07-22 | Mesa Internal Medicine Associates | $238.00 | Approved |
| CLM-2026-011546 | 2026-07-30 | Valley Primary Care Associates | $293.00 | Approved |
| CLM-2026-000633 | 2026-04-16 | Sunrise Dermatology Clinic | $638.00 | Denied |
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.