CLM-2026-021098
Valley Digestive Health Center, Gastroenterology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Henry Reynolds
- Member ID
- UHC-89188-18
- Date of birth
- 2002-08-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414122
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4166
- Coverage period
- 2024-01-01 to present
- Deductible
- $2,120.45 of $2,500.0085%
- Out-of-pocket maximum
- $609.33 of $7,500.008%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 1762583643
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2025922674 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,389.00 | $763.95 | $417.99 | $345.96 | Paid |
| Totals | $1,389.00 | $763.95 | $417.99 | $345.96 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-675004
- 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-003843 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-05: MEDICARE-ADV-B (MA), effective 2024-01-01. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025922674 on file for 43239. | |
| 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 Center2026-09-05 16:21
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025922674_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-09-05 to 2026-12-04.
- Itemized billitemized_PA-675004.pdf9 pages
Itemised statement totalling $1389.00 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-2026-003843 | 2026-07-20 | Lakeside Heart Institute | $259.00 | Approved |
| CLM-2026-000277 | 2025-12-25 | Lakeside Heart Institute | $606.00 | Approved |
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.