CLM-2026-026931
Riverside Digestive Health Center, Gastroenterology. Service 2025-12-17 at outpatient hospital (POS 22). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Victoria Cooper
- Member ID
- UHC-00539-49
- Date of birth
- 1960-10-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411470
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5228
- Coverage period
- 2022-09-01 to present
- Deductible
- $401.99 of $1,000.0040%
- Out-of-pocket maximum
- $562.55 of $2,000.0028%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 5957681559
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2025848120 / REF681401
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 | $2,169.00 | $1,192.95 | — | — | Review |
| Totals | $2,169.00 | $1,192.95 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-287551
- 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-003485 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-17: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025848120 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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: “Established patient presents with encounter for screening for malignant neoplasm of colon;”. 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: Riverside Digestive Health Center2025-12-17 10:06
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-27 05:26
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-27 15:31
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025848120_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-17 to 2026-03-17.
- Itemized billitemized_PA-287551.pdf7 pages
Itemised statement totalling $2169.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with encounter for screening for malignant neoplasm of colon;”.
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.