CLM-2026-021341
Canyon GI Associates, Gastroenterology. Service 2026-08-27 at outpatient hospital (POS 22). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Kathryn Robinson
- Member ID
- UHC-69124-67
- Date of birth
- 1968-05-13
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-419900
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7620
- Coverage period
- 2022-01-01 to present
- Deductible
- $155.45 of $500.0031%
- Out-of-pocket maximum
- $50.86 of $2,000.003%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 5147501469
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- none / 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 | $2,417.00 | $1,329.35 | — | — | DeniedCO197 |
| Totals | $2,417.00 | $1,329.35 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-845624
- 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-003509 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-27: - (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Associates2026-08-27 14:57
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-10-03 06:12
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-10-03 15:37
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-845624.pdf4 pages
Itemised statement totalling $2417.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025409 | 2026-05-12 | Canyon Medical Group | $387.00 | Approved |
| CLM-2026-007244 | 2025-11-26 | Northgate Clinical Laboratories | $74.00 | Denied |
| CLM-2026-008822 | 2026-01-04 | Desert Reference Lab | $114.00 | 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.