CLM-2026-027788
Unity Digestive Health Center, Gastroenterology. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Cmaila Jimenez
- Member ID
- UHC-71123-92
- Date of birth
- 1975-10-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406241
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7110
- Coverage period
- 2024-05-01 to present
- Deductible
- $1,047.13 of $2,500.0042%
- Out-of-pocket maximum
- $4,093.69 of $10,000.0041%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 7674248878
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- none / 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 | $1,761.00 | $968.55 | — | — | DeniedCO197 |
| Totals | $1,761.00 | $968.55 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-706791
- 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-043185 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-21: N/A (PPO), effective 2024-05-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-08-21 13:39
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-02 01:27
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-706791.pdf2 pages
Itemised statement totalling $1761.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008930 | 2026-01-25 | Unity Cardiovascular Associates | $256.00 | Denied |
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
Precertification required and absent.