CLM-2026-020468
Valley Digestive Health Center, Gastroenterology. Service 2026-04-20 at outpatient hospital (POS 22). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Benjamin Welch
- Member ID
- UHC-88140-28
- Date of birth
- 2001-07-14
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-415647
- Relationship
- Spouse, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6197
- Coverage period
- 2022-10-01 to present
- Deductible
- $912.62 of $1,500.0061%
- Out-of-pocket maximum
- $1,756.96 of $6,000.0029%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 4512794692
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- none / REF869694
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 | $2,366.00 | $1,301.30 | — | — | DeniedCO197 |
| Totals | $2,366.00 | $1,301.30 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-678264
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-029035 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-20: NAVIGATE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2026-04-20 14:47
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-05-18 05:22
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-18 17:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-678264.pdf7 pages
Itemised statement totalling $2366.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027242 | 2026-05-02 | Pinecrest GI Associates | $2,828.00 | Approved |
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.