CLM-2026-024443
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-07-11 at outpatient hospital (POS 22). Received 2026-08-24.
Member
Resolved through the identity graph
- Member
- Elijah Stewart
- Member ID
- UHC-98332-21
- Date of birth
- 1979-05-06
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-424841
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3938
- Coverage period
- 2022-03-01 to present
- Deductible
- $834.12 of $1,000.0083%
- Out-of-pocket maximum
- $1,274.21 of $4,000.0032%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 7457769264
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- PA2025117791 / 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 | $1,400.00 | $770.00 | $286.70 | $483.30 | Paid |
| Totals | $1,400.00 | $770.00 | $286.70 | $483.30 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-961477
- 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-040900 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-11: MEDICARE-ADV-B (MA), effective 2022-03-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025117791 on file for 45378. | |
| Provider network | Pass | In-network provider Cornerstone Digestive Health Center (4838407417). | |
| 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: Cornerstone Digestive Health Center2026-07-11 13:53
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025117791_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-11 to 2026-10-09.
- Itemized billitemized_PA-961477.pdf7 pages
Itemised statement totalling $1400.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 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.