CLM-2026-029057
Riverside Digestive Health Center, Gastroenterology. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Wayne Cunningham
- Member ID
- UHC-85486-78
- Date of birth
- 1948-05-12
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-405378
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0739
- Coverage period
- 2022-08-01 to 2026-07-13
- Deductible
- $442.50 of $1,000.0044%
- Out-of-pocket maximum
- $420.38 of $3,000.0014%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 3232721332
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2025688986 / REF239978
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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $311.00 | $171.05 | — | — | DeniedCO27 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,917.00 | $1,054.35 | — | — | DeniedCO27 |
| Totals | $2,228.00 | $1,225.40 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-698875
- 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-013973 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-21 is after coverage terminated on 2026-07-13. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025688986 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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: Riverside Digestive Health Center2026-07-21 15:57
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-08-12 06:44
Attachments
Documents received with the claim
- Prior auth letterPA2025688986_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-21 to 2026-10-19.
- Itemized billitemized_PA-698875.pdf6 pages
Itemised statement totalling $2228.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-21 is after coverage terminated on 2026-07-13.
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.