CLM-2026-026685
Riverside GI Associates, Gastroenterology. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Andrea Cole
- Member ID
- UHC-40033-82
- Date of birth
- 2007-01-25
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-412925
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6567
- Coverage period
- 2023-09-01 to 2026-03-08
- Deductible
- $226.37 of $500.0045%
- Out-of-pocket maximum
- $512.25 of $1,500.0034%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 6448742364
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2026240394 / 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 | $1,317.00 | $724.35 | — | — | DeniedCO27 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $2,651.00 | $1,458.05 | — | — | DeniedCO27 |
| Totals | $3,968.00 | $2,182.40 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-659609
- 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-028386 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-03 is after coverage terminated on 2026-03-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026240394 on file for 43239, 45378. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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: Riverside GI Associates2026-05-03 12:04
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-06-17 03:15
Attachments
Documents received with the claim
- Prior auth letterPA2026240394_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-659609.pdf2 pages
Itemised statement totalling $3968.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-03 is after coverage terminated on 2026-03-08.
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.