CLM-2026-018714
Canyon GI Associates, Gastroenterology. Service 2026-02-10 at outpatient hospital (POS 22). Received 2026-02-17.
Member
Resolved through the identity graph
- Member
- Maria Jones
- Member ID
- UHC-59633-24
- Date of birth
- 1981-12-28
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-422280
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4222
- Coverage period
- 2024-11-01 to present
- Deductible
- $16.34 of $3,500.000%
- Out-of-pocket maximum
- $1,244.49 of $10,500.0012%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 9849623928
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2026879979 / 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 | $2,240.00 | $1,232.00 | $1,232.00 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $252.00 | $138.60 | $138.60 | $0.00 | Paid |
| Totals | $2,492.00 | $1,370.60 | $1,370.60 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-802432
- 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-013704 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-10: SELECT-EPO (EPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026879979 on file for 45378. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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: Canyon GI Associates2026-02-10 18:07
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026879979_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-10 to 2026-05-11.
- Itemized billitemized_PA-802432.pdf7 pages
Itemised statement totalling $2492.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.