CLM-2026-025292
Lakeside Digestive Health Center, Gastroenterology. Service 2026-04-13 at outpatient hospital (POS 22). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Mateeo Williamson
- Member ID
- UHC-09947-95
- Date of birth
- 1940-08-16
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432593
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-1821
- Coverage period
- 2021-08-01 to present
- Deductible
- $495.06 of $1,500.0033%
- Out-of-pocket maximum
- $306.91 of $4,500.007%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 6071093572
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2026034658 / 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 | $1,823.00 | $1,002.65 | $1,002.65 | $0.00 | Paid |
| Totals | $1,823.00 | $1,002.65 | $1,002.65 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-583677
- 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-031923 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-13: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026034658 on file for 43239. | |
| 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 Center2026-04-13 14:05
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026034658_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-04-13 to 2026-07-12.
- Itemized billitemized_PA-583677.pdf6 pages
Itemised statement totalling $1823.00 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.