CLM-2026-022824
Riverside Digestive Health Center, Gastroenterology. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-04-21.
Member
Resolved through the identity graph
- Member
- Roger Rodriguez
- Member ID
- UHC-43606-52
- Date of birth
- 1956-03-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-412135
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7193
- Coverage period
- 2022-06-01 to present
- Deductible
- $30.43 of $1,000.003%
- Out-of-pocket maximum
- $1,280.37 of $3,000.0043%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 4835365972
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026134534 / 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 | $1,889.00 | $1,038.95 | $983.45 | $55.50 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $242.00 | $133.10 | $26.62 | $106.48 | Paid |
| Totals | $2,131.00 | $1,172.05 | $1,010.07 | $161.98 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-376697
- 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-027038 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-07: MEDICARE-ADV-B (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026134534 on file for 45378. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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 Center2026-04-07 11:00
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026134534_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-04-07 to 2026-07-06.
- Itemized billitemized_PA-376697.pdf4 pages
Itemised statement totalling $2131.00 across 2 lines.
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
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.