CLM-2026-022942
Riverside GI Associates, Gastroenterology. Service 2026-04-06 at outpatient hospital (POS 22). Received 2026-05-14.
Member
Resolved through the identity graph
- Member
- Larry Barnes
- Member ID
- UHC-76599-05
- Date of birth
- 1958-04-09
- Identity
- Verified7 records, confidence 0.96
- Claim record
- CLMCLM-406037
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3520
- Coverage period
- 2024-08-01 to present
- Deductible
- $190.80 of $1,500.0013%
- Out-of-pocket maximum
- $1,402.43 of $4,500.0031%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 8052188793
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2025744906 / 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 | $2,184.00 | $1,201.20 | $1,201.20 | $0.00 | Paid |
| Totals | $2,184.00 | $1,201.20 | $1,201.20 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-679077
- 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-024690 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-06: MEDICARE-ADV-A (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025744906 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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 GI Associates2026-04-06 14:05
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025744906_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-04-06 to 2026-07-05.
- Itemized billitemized_PA-679077.pdf4 pages
Itemised statement totalling $2184.00 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-2026-028586 | 2026-09-23 | Meadow Imaging Center | $2,651.00 | Needs review |
| CLM-2026-031641 | 2026-08-20 | Sunrise Internal Medicine Associates | $342.00 | Approved |
| CLM-2026-004825 | 2026-05-09 | Mesa Medical Group | $259.00 | Approved |
| CLM-2026-032633 | 2026-04-07 | Lakeside Regional Medical Center | $255.00 | 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.