CLM-2026-026869
Meadow GI Associates, Gastroenterology. Service 2025-10-21 at outpatient hospital (POS 22). Received 2026-02-11.
Member
Resolved through the identity graph
- Member
- George Kennedy
- Member ID
- UHC-87028-23
- Date of birth
- 1953-06-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422938
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9342
- Coverage period
- 2021-10-01 to present
- Deductible
- $510.06 of $2,500.0020%
- Out-of-pocket maximum
- $154.30 of $5,000.003%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 6926024889
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025823507 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $214.00 | $96.30 | — | — | DeniedCO29 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $2,650.00 | $1,192.50 | — | — | DeniedCO29 |
| Totals | $2,864.00 | $1,288.80 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-878218
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012174 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-10-21: OPTIONS-PPO (PPO), effective 2021-10-01. | |
| Timely filing | Fail | CO29 | Received 113 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025823507 on file for 45378. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow GI Associates2025-10-21 18:56
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-02-11 05:12
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2025823507_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2025-10-21 to 2026-01-19.
- Itemized billitemized_PA-878218.pdf2 pages
Itemised statement totalling $2864.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 113 days after the last date of service (limit 90). Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
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
Received after the timely-filing limit.