CLM-2026-029795
Riverside GI Associates, Gastroenterology. Service 2026-07-14 at outpatient hospital (POS 22). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Joan Young
- Member ID
- none on golden record
- Date of birth
- 1941-11-21
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428006
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group GRP-2978
- Coverage period
- 2024-12-01 to present
- Deductible
- $280.19 of $1,000.0028%
- Out-of-pocket maximum
- $505.40 of $4,000.0013%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7858029219
- Network
- In network
- Rendering NPI
- 9429107946
- Location
- San Diego, CA · TIN 69-3440792
- Authorisation / referral
- PA2025385246 / 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 | $2,005.00 | $1,102.75 | — | — | PendedIDQ |
| Totals | $2,005.00 | $1,102.75 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-325930
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
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-003306; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-07-14: SELECT-EPO (EPO), effective 2024-12-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025385246 on file for 45378. | |
| Provider network | Pass | In-network provider Riverside GI Associates (7858029219). | |
| 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 GI Associates2026-07-14 10:57
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025385246_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-14 to 2026-10-12.
- Itemized billitemized_PA-325930.pdf3 pages
Itemised statement totalling $2005.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003306; payment withheld until the identity is confirmed. Eligibility: Active on 2026-07-14: SELECT-EPO (EPO), effective 2024-12-01. 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.