CLM-2026-025901
Valley Digestive Health Center, Gastroenterology. Service 2026-08-20 at outpatient hospital (POS 22). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Ronnald Vasquez
- Member ID
- UHC-38639-35
- Date of birth
- 1941-12-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-411868
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5832
- Coverage period
- 2023-04-01 to present
- Deductible
- $205.19 of $2,500.008%
- Out-of-pocket maximum
- $4,930.38 of $10,000.0049%
- Copays
- office $20.00, specialist $50.00, 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
- 6355422992
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- PA2026506103 / REF754726
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 | $1,350.00 | $742.50 | $742.50 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $1,749.00 | $961.95 | $961.95 | $0.00 | Paid |
| 3 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $342.00 | $188.10 | $188.10 | $0.00 | Paid |
| Totals | $3,441.00 | $1,892.55 | $1,892.55 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-633941
- 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-040932 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-20: CORE-HMO (HMO), effective 2023-04-01. | |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026506103 on file for 43239, 45378. | |
| 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 Center2026-08-20 14:56
Patient seen for gastro-esophageal reflux disease without esophagitis.
Attachments
Documents received with the claim
- Prior auth letterPA2026506103_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-20 to 2026-11-18.
- Itemized billitemized_PA-633941.pdf2 pages
Itemised statement totalling $3441.00 across 3 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
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.