CLM-2026-029854
Riverside Digestive Health Center, Gastroenterology. Service 2026-09-04 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Joan Maldonado
- Member ID
- UHC-93987-64
- Date of birth
- 1990-12-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-421011
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8476
- Coverage period
- 2024-10-01 to present
- Deductible
- $2,061.47 of $2,500.0082%
- Out-of-pocket maximum
- $1,126.95 of $7,500.0015%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 2082772908
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026246205 / 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 | $2,230.00 | $1,226.50 | $517.33 | $709.17 | Paid |
| Totals | $2,230.00 | $1,226.50 | $517.33 | $709.17 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-918833
- 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-018192 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-04: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026246205 on file for 45378. | |
| 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 Center2026-09-04 17:10
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026246205_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-04 to 2026-12-03.
- Itemized billitemized_PA-918833.pdf5 pages
Itemised statement totalling $2230.00 across 1 line.
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-2026-029966 | 2026-07-24 | Riverside Internal Medicine Associates | $83.00 | Denied |
| CLM-2026-029965 | 2026-07-24 | Riverside Internal Medicine Associates | $83.00 | Approved |
| CLM-2026-006446 | 2026-02-22 | Meadow Diagnostic Imaging | $166.00 | 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.