CLM-2026-029678
Canyon GI Associates, Gastroenterology. Service 2026-02-06 at outpatient hospital (POS 22). Received 2026-03-03.
Member
Resolved through the identity graph
- Member
- Isabella Edwards
- Member ID
- none on golden record
- Date of birth
- 1948-09-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-423973
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- OPTIONS-PPO PPO group GRP-2332
- Coverage period
- 2022-05-01 to present
- Deductible
- $2,233.76 of $3,500.0064%
- Out-of-pocket maximum
- $2,006.25 of $14,000.0014%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 4231391564
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2026720968 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $245.00 | $134.75 | — | — | PendedIDQ |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,599.00 | $1,429.45 | — | — | PendedIDQ |
| Totals | $2,844.00 | $1,564.20 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-705010
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001144; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-06: OPTIONS-PPO (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 PA2026720968 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 Associates2026-02-06 14:08
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026720968_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-02-06 to 2026-05-07.
- Itemized billitemized_PA-705010.pdf3 pages
Itemised statement totalling $2844.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001144; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-06: OPTIONS-PPO (PPO), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.