CLM-2026-018855
Riverside Digestive Health Center, Gastroenterology. Service 2026-08-13 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Diego Marquez
- Member ID
- UHC-16469-95
- Date of birth
- 1993-02-10
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-412618
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8014
- Coverage period
- 2022-01-01 to 2026-04-10
- Deductible
- $770.13 of $1,000.0077%
- Out-of-pocket maximum
- $849.56 of $3,000.0028%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 7331043290
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2026452748 / REF186226
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 | $2,253.00 | $1,239.15 | — | — | DeniedCO27 |
| Totals | $2,253.00 | $1,239.15 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-661474
- 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-025413 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-13 is after coverage terminated on 2026-04-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026452748 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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 Center2026-08-13 17:00
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-19 03:20
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-19 08:02
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026452748_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-13 to 2026-11-11.
- Itemized billitemized_PA-661474.pdf7 pages
Itemised statement totalling $2253.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-13 is after coverage terminated on 2026-04-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003355 | 2026-07-23 | Summit Cardiovascular Associates | $8,112.00 | Denied |
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
Service after coverage termination.