CLM-2026-022510
Riverside Digestive Health Center, Gastroenterology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Melissa Anderson
- Member ID
- UHC-00123-95
- Date of birth
- 1981-07-02
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416424
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2990
- Coverage period
- 2023-08-01 to present
- Deductible
- $197.42 of $2,500.008%
- Out-of-pocket maximum
- $4,485.14 of $10,000.0045%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 9022250978
- Location
- Tempe, AZ · TIN 41-1081863
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $224.00 | $123.20 | $123.20 | $0.00 | Paid |
| Totals | $224.00 | $123.20 | $123.20 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-673608
- 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-018684 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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: Riverside Digestive Health Center2026-08-20 16:37
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-673608.pdf5 pages
Itemised statement totalling $224.00 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-2026-022511 | 2026-08-20 | Riverside Digestive Health Center | $224.00 | Denied |
| CLM-2026-008574 | 2026-03-21 | Cornerstone Cardiovascular Associates | $8,446.00 | Approved |
| CLM-2026-013683 | 2026-03-01 | Lakeside Bone and Joint Center | $40,153.00 | Needs review |
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.