CLM-2026-022340
Lakeside Digestive Health Center, Gastroenterology. Service 2026-07-19 at outpatient hospital (POS 22). Received 2026-07-21.
Member
Resolved through the identity graph
- Member
- Patrick Le
- Member ID
- UHC-86550-30
- Date of birth
- 2007-07-13
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-411843
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8650
- Coverage period
- 2024-04-01 to present
- Deductible
- $544.46 of $1,000.0054%
- Out-of-pocket maximum
- $471.21 of $4,000.0012%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 7160961679
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2025099718 / 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 | $1,823.00 | $1,002.65 | $510.25 | $492.40 | Paid |
| Totals | $1,823.00 | $1,002.65 | $510.25 | $492.40 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-198026
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020318 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-19: MEDICARE-ADV-A (MA), effective 2024-04-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025099718 on file for 43239. | |
| Provider network | Pass | In-network provider Lakeside Digestive Health Center (5154884873). | |
| 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: Lakeside Digestive Health Center2026-07-19 18:58
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025099718_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-07-19 to 2026-10-17.
- Itemized billitemized_PA-198026.pdf5 pages
Itemised statement totalling $1823.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027155 | 2026-06-10 | Sunrise Cardiovascular Associates | $7,103.00 | Approved |
| CLM-2026-015608 | 2026-02-21 | Heritage Internal Medicine Associates | $393.00 | 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.