CLM-2026-027533
Meadow GI Associates, Gastroenterology. Service 2026-08-05 at outpatient hospital (POS 22). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Priya Williams
- Member ID
- UHC-70691-50
- Date of birth
- 1972-03-23
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-432241
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7122
- Coverage period
- 2022-07-01 to present
- Deductible
- $1,963.77 of $3,500.0056%
- Out-of-pocket maximum
- $739.81 of $7,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 9241016242
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025643203 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,140.00 | $963.00 | $963.00 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $320.00 | $144.00 | $144.00 | $0.00 | Paid |
| Totals | $2,460.00 | $1,107.00 | $1,107.00 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-958895
- 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-033534 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-05: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025643203 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 Associates2026-08-05 17:07
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025643203_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-05 to 2026-11-03.
- Itemized billitemized_PA-958895.pdf8 pages
Itemised statement totalling $2460.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028050 | 2026-09-22 | Cornerstone Digestive Health Center | $1,752.00 | Approved |
| CLM-2026-016990 | 2026-06-24 | Meadow Heart Institute | $754.00 | Approved |
| CLM-2026-026960 | 2026-05-02 | Pinecrest Diagnostic Imaging | $2,712.00 | Needs review |
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.