CLM-2026-024307
Meadow GI Associates, Gastroenterology. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Andrew James
- Member ID
- UHC-35033-47
- Date of birth
- 1938-01-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-428018
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4376
- Coverage period
- 2021-07-01 to present
- Deductible
- $315.33 of $1,000.0032%
- Out-of-pocket maximum
- $279.69 of $2,000.0014%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 7747473727
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2026503958 / REF959307
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 | $2,004.00 | $901.80 | — | — | DeniedCO204 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $349.00 | $157.05 | — | — | DeniedCO204 |
| Totals | $2,353.00 | $1,058.85 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-865525
- 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-023400 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: CORE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026503958 on file for 45378. | |
| Provider network | Fail | CO204 | Billing provider 7747243401 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Meadow GI Associates2026-03-10 13:28
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-04-01 05:10
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
Attachments
Documents received with the claim
- Prior auth letterPA2026503958_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-03-10 to 2026-06-08.
- Itemized billitemized_PA-865525.pdf5 pages
Itemised statement totalling $2353.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Provider network: Billing provider 7747243401 is out of network and the HMO plan has no out-of-network benefit.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027454 | 2026-07-12 | Sunrise Heart Institute | $7,407.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.