CLM-2026-028922
Unity Digestive Health Center, Gastroenterology. Service 2026-06-11 at outpatient hospital (POS 22). Received 2026-06-18.
Member
Resolved through the identity graph
- Member
- Joyce Reid
- Member ID
- UHC-05392-10
- Date of birth
- 1965-10-13
- Identity
- Verified6 records, confidence 0.98
- Claim record
- CLMCLM-419015
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7911
- Coverage period
- 2022-07-01 to present
- Deductible
- $444.64 of $500.0089%
- Out-of-pocket maximum
- $51.14 of $1,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 5587526463
- Location
- Austin, TX · TIN 73-9134731
- Authorisation / referral
- PA2025899464 / 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 | $1,500.00 | $825.00 | $209.29 | $615.71 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,312.00 | $721.60 | $144.32 | $577.28 | Paid |
| Totals | $2,812.00 | $1,546.60 | $353.61 | $1,192.99 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-334093
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016301 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-06-11: MEDICARE-ADV-B (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025899464 on file for 45378, 43239. | |
| 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 Center2026-06-11 10:08
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025899464_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-06-11 to 2026-09-09.
- Itemized billitemized_PA-334093.pdf8 pages
Itemised statement totalling $2812.00 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 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005725 | 2026-08-30 | Cornerstone Reference Lab | $108.00 | Needs review |
| CLM-2026-005724 | 2026-08-30 | Cornerstone Reference Lab | $108.00 | Approved |
| CLM-2026-028042 | 2026-03-02 | Sunrise Internal Medicine Associates | $449.00 | Approved |
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.