CLM-2026-023675
Meadow GI Associates, Gastroenterology. Service 2026-05-31 at outpatient hospital (POS 22). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Daniel Wbeb
- Member ID
- UHC-96158-05
- Date of birth
- 1949-01-06
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-432772
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9751
- Coverage period
- 2021-09-01 to present
- Deductible
- $509.43 of $1,000.0051%
- Out-of-pocket maximum
- $89.61 of $3,000.003%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1813475971
- Network
- In network
- Rendering NPI
- 6251664515
- Location
- Austin, TX · TIN 38-1568789
- Authorisation / referral
- PA2026425234 / 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 | $2,022.00 | $1,112.10 | — | — | Review |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $265.00 | $145.75 | — | — | Review |
| Totals | $2,287.00 | $1,257.85 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-387776
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038483 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-31: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026425234 on file for 45378. | |
| Provider network | Pass | In-network provider Meadow GI Associates (1813475971). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; sign”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Meadow GI Associates2026-05-31 15:41
Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-15 02:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2026425234_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-05-31 to 2026-08-29.
- Itemized billitemized_PA-387776.pdf6 pages
Itemised statement totalling $2287.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for epigastric pain. Plan discussed, medications reconciled. Note dictated; sign”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.