CLM-2026-026861
Riverside Digestive Health Center, Gastroenterology. Service 2026-07-20 at office (POS 11). Received 2026-08-15.
Member
Resolved through the identity graph
- Member
- Samantha Guzman
- Member ID
- UHC-92739-37
- Date of birth
- 1969-12-26
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403705
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6819
- Coverage period
- 2024-11-01 to present
- Deductible
- $414.62 of $500.0083%
- Out-of-pocket maximum
- $288.76 of $2,000.0014%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 8610562406
- Location
- Atlanta, GA · TIN 82-1240911
- 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 | $310.00 | $192.20 | — | — | DeniedCO18 |
| Totals | $310.00 | $192.20 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-392296
- 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-023571 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-20: N/A (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-026860: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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 Digestive Health Center2026-07-20 10:12
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-15 00:22
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-026860: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014023 | 2026-07-17 | Sunrise Imaging Center | $2,387.00 | Approved |
| CLM-2026-026860 | 2026-07-20 | Riverside Digestive Health Center | $310.00 | Approved |
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
Exact duplicate of an earlier submission.