CLM-2026-025618
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-10-13 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Janet Delgado
- Member ID
- UHC-86657-86
- Date of birth
- 1962-11-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422695
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2841
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,458.44 of $2,500.0058%
- Out-of-pocket maximum
- $3,615.22 of $10,000.0036%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 3601244874
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- PA2026372532 / 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 | $1,476.00 | $811.80 | — | — | Review |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $260.00 | $143.00 | — | — | Review |
| Totals | $1,736.00 | $954.80 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-435665
- 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-021095 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-10-13: CHOICE-PLUS-PPO (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026372532 on file for 43239. | |
| 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 | Review | CO16 | Documentation incomplete: “Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, med”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Cornerstone Digestive Health Center2026-10-13 09:36
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-18 02:58
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-18 12:59
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026372532_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-10-13 to 2027-01-11.
- Itemized billitemized_PA-435665.pdf6 pages
Itemised statement totalling $1736.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, med”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.