CLM-2026-028186
Canyon GI Associates, Gastroenterology. Service 2026-05-26 at outpatient hospital (POS 22). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Santiago Garza
- Member ID
- UHC-94718-70
- Date of birth
- 1994-07-26
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-409868
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-6499
- Coverage period
- 2025-09-01 to 2026-05-03
- Deductible
- $820.85 of $2,500.0033%
- Out-of-pocket maximum
- $1,790.84 of $7,500.0024%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 4632364707
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2026511474 / REF299419
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 | $2,034.00 | $1,118.70 | — | — | DeniedCO27 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | 25 | 1 | 2 | $256.00 | $140.80 | — | — | DeniedCO27 |
| Totals | $2,290.00 | $1,259.50 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-626604
- 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-021244 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-26 is after coverage terminated on 2026-05-03. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026511474 on file for 45378. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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: Canyon GI Associates2026-05-26 13:04
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-20 01:55
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-20 09:46
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026511474_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-05-26 to 2026-08-24.
- Itemized billitemized_PA-626604.pdf7 pages
Itemised statement totalling $2290.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-05-26 is after coverage terminated on 2026-05-03.
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
Service after coverage termination.