CLM-2026-023199
Lakeside Digestive Health Center, Gastroenterology. Service 2026-01-30 at outpatient hospital (POS 22). Received 2026-02-26.
Member
Resolved through the identity graph
- Member
- Harold Herrera
- Member ID
- UHC-36675-86
- Date of birth
- 1987-04-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420485
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0574
- Coverage period
- 2025-04-01 to present
- Deductible
- $329.95 of $2,500.0013%
- Out-of-pocket maximum
- $3,665.82 of $10,000.0037%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 1787865215
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2025213694 / 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 | $1,380.00 | $759.00 | $759.00 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $209.00 | $114.95 | $114.95 | $0.00 | Paid |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $1,458.00 | $801.90 | $801.90 | $0.00 | Paid |
| Totals | $3,047.00 | $1,675.85 | $1,675.85 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-904520
- 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-015937 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-30: SELECT-EPO (EPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025213694 on file for 43239, 45378. | |
| 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 Center2026-01-30 15:42
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025213694_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-30 to 2026-04-30.
- Itemized billitemized_PA-904520.pdf3 pages
Itemised statement totalling $3047.00 across 3 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.