CLM-2026-025425
Valley Digestive Health Center, Gastroenterology. Service 2026-05-15 at office (POS 11). Received 2026-06-22.
Member
Resolved through the identity graph
- Member
- Blily Chapman
- Member ID
- UHC-98525-46
- Date of birth
- 1967-07-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-432378
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7959
- Coverage period
- 2023-11-01 to 2026-02-05
- Deductible
- $847.10 of $1,500.0056%
- Out-of-pocket maximum
- $1,820.98 of $4,500.0040%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 2462838311
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $244.00 | $151.28 | — | — | DeniedCO27 |
| Totals | $244.00 | $151.28 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-813913
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035871 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-15 is after coverage terminated on 2026-02-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Digestive Health Center (9396653484). | |
| 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: Valley Digestive Health Center2026-05-15 13:51
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-22 00:03
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-15 is after coverage terminated on 2026-02-05.
Other claims for this member
Same resolved identity
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
Service after coverage termination.