CLM-2026-022170
Unity Digestive Health Center, Gastroenterology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-08-28.
Member
Resolved through the identity graph
- Member
- Raymond Hall
- Member ID
- UHC-66052-13
- Date of birth
- 1978-08-11
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402016
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3953
- Coverage period
- 2025-09-01 to 2026-07-23
- Deductible
- $176.54 of $1,000.0018%
- Out-of-pocket maximum
- $1,381.79 of $3,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 2222317366
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PA2025734001 / REF269977
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 | $2,061.00 | $1,133.55 | — | — | DeniedCO27 |
| Totals | $2,061.00 | $1,133.55 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-431102
- 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-017165 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-20 is after coverage terminated on 2026-07-23. Expenses incurred after coverage terminated |
| 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 PA2025734001 on file for 43239. | |
| 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 Center2026-08-20 12:09
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-28 03:48
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-28 16:59
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025734001_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-20 to 2026-11-18.
- Itemized billitemized_PA-431102.pdf6 pages
Itemised statement totalling $2061.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-20 is after coverage terminated on 2026-07-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028801 | 2026-08-03 | Meadow Medical Group | $321.00 | 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.