CLM-2026-018226
Summit Digestive Health Center, Gastroenterology. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-09.
Member
Resolved through the identity graph
- Member
- Charlotte Espinoza
- Member ID
- UHC-63127-60
- Date of birth
- 2002-11-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412258
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-2460
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,287.27 of $2,500.0051%
- Out-of-pocket maximum
- $1,021.73 of $5,000.0020%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 1830072561
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- none / REF359377
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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,585.00 | $871.75 | — | — | DeniedCO197 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $1,672.00 | $919.60 | — | — | DeniedCO197 |
| Totals | $3,257.00 | $1,791.35 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-395138
- 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-034191 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-06: CORE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239, 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Summit Digestive Health Center (1126576986). | |
| 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: Summit Digestive Health Center2026-06-06 11:26
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-06-09 00:39
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-395138.pdf4 pages
Itemised statement totalling $3257.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 43239, 45378 require precertification; no authorisation number on the claim.
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
Precertification required and absent.