CLM-2026-022866
Valley Digestive Health Center, Gastroenterology. Service 2026-03-20 at outpatient hospital (POS 22). Received 2026-04-09.
Member
Resolved through the identity graph
- Member
- Terry Butler
- Member ID
- UHC-98914-41
- Date of birth
- 2008-10-10
- Identity
- Verified5 records, confidence 0.98
- Claim record
- CLMCLM-426572
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5125
- Coverage period
- 2023-07-01 to present
- Deductible
- $882.53 of $2,500.0035%
- Out-of-pocket maximum
- $2,216.37 of $5,000.0044%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 5893120324
- Location
- Los Angeles, CA · TIN 94-4926360
- 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 | $287.00 | $157.85 | $157.85 | $0.00 | Paid |
| Totals | $287.00 | $157.85 | $157.85 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-993476
- 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-009678 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-03-20: MEDICARE-ADV-A (MA), effective 2023-07-01. | |
| Timely filing | Pass | Received 20 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 Valley Digestive Health Center (9396653484). | |
| 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: Valley Digestive Health Center2026-03-20 18:30
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-993476.pdf5 pages
Itemised statement totalling $287.00 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-2026-000188 | 2026-03-01 | Mesa Family Practice | $181.00 | Approved |
| CLM-2026-005633 | 2026-02-25 | Sunrise Community Hospital | $234.00 | 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.