CLM-2026-028463
Valley Digestive Health Center, Gastroenterology. Service 2025-12-24 at office (POS 11). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Logan Bailey
- Member ID
- UHC-62349-08
- Date of birth
- 2001-10-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-416602
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8027
- Coverage period
- 2024-02-01 to present
- Deductible
- $462.85 of $2,500.0019%
- Out-of-pocket maximum
- $473.28 of $10,000.005%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9396653484
- Network
- In network
- Rendering NPI
- 5212319987
- Location
- Los Angeles, CA · TIN 94-4926360
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $269.00 | $166.78 | — | — | Review |
| Totals | $269.00 | $166.78 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-856430
- 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-001890 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-24: SELECT-EPO (EPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Valley Digestive Health Center (9396653484). | |
| 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: “Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconcil”. 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: Valley Digestive Health Center2025-12-24 16:17
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-06 05:45
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconcil”.
- AI recommendationPended2026-10-21 14:15The claim is pended due to incomplete documentation. The clinical note [N1] is missing a signature, and a development letter has been sent to the provider [N2]. The claim cannot be adjudicated until the documentation is complete.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 1bab1d23
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034529 | 2026-07-06 | Evergreen Digestive Health Center | $2,418.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO16 Claim lacks information needed for adjudication
The claim is pended due to incomplete documentation. The clinical note [N1] is missing a signature, and a development letter has been sent to the provider [N2]. The claim cannot be adjudicated until the documentation is complete.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO16 Claim lacks information needed for adjudication
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.