CLM-2026-021400
Unity Digestive Health Center, Gastroenterology. Service 2026-06-26 at outpatient hospital (POS 22). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Albert Hall
- Member ID
- UHC-09057-91
- Date of birth
- 1981-10-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415052
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-9430
- Coverage period
- 2023-11-01 to present
- Deductible
- $2,117.71 of $3,500.0061%
- Out-of-pocket maximum
- $988.94 of $7,000.0014%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 6920963207
- Location
- Austin, TX · TIN 73-9134731
- 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 | $2,478.00 | $1,362.90 | — | — | DeniedCO197 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,878.00 | $1,032.90 | — | — | DeniedCO197 |
| Totals | $4,356.00 | $2,395.80 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-885792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003841; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-26: UNKNOWN (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378, 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-06-26 09:02
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-07-01 06:16
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-885792.pdf7 pages
Itemised statement totalling $4356.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-003841; payment withheld until the identity is confirmed. Prior authorisation: 45378, 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.