CLM-2026-025169
Unity Digestive Health Center, Gastroenterology. Service 2026-05-10 at outpatient hospital (POS 22). Received 2026-06-08.
Member
Resolved through the identity graph
- Member
- Diego Willis
- Member ID
- UHC-55353-42
- Date of birth
- 1945-11-19
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-428783
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8034
- Coverage period
- 2022-08-01 to 2026-08-06
- Deductible
- $1,216.86 of $3,500.0035%
- Out-of-pocket maximum
- $2,748.40 of $7,000.0039%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 6390214354
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PA2025314316 / REF331606
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 | $1,376.00 | $756.80 | $756.80 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $289.00 | $158.95 | $158.95 | $0.00 | Paid |
| Totals | $1,665.00 | $915.75 | $915.75 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-594638
- 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-031644 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-10: CORE-HMO (HMO), effective 2022-08-01, terms 2026-08-06. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025314316 on file for 43239. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-05-10 15:00
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025314316_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-10 to 2026-08-08.
- Itemized billitemized_PA-594638.pdf5 pages
Itemised statement totalling $1665.00 across 2 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010512 | 2026-07-13 | Riverside Community Hospital | $4,191.00 | Approved |
| CLM-2026-013037 | 2026-04-18 | Meadow Diagnostic Imaging | $3,692.00 | Denied |
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.