CLM-2026-030221
Cornerstone Digestive Health Center, Gastroenterology. Service 2026-03-22 at outpatient hospital (POS 22). Received 2026-04-15.
Member
Resolved through the identity graph
- Member
- Cheryl Henry
- Member ID
- UHC-97793-44
- Date of birth
- 1955-08-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-403376
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group NULL
- Coverage period
- 2024-06-01 to present
- Deductible
- $88.38 of $500.0018%
- Out-of-pocket maximum
- $349.92 of $1,000.0035%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4838407417
- Network
- In network
- Rendering NPI
- 2175891714
- Location
- Los Angeles, CA · TIN 73-5559083
- Authorisation / referral
- none / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,557.00 | $856.35 | — | — | DeniedCO197 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $280.00 | $154.00 | — | — | DeniedCO197 |
| Totals | $1,837.00 | $1,010.35 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-526642
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012739 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-22: UNKNOWN (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Cornerstone Digestive Health Center (4838407417). | |
| 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: Cornerstone Digestive Health Center2026-03-22 15:22
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-04-15 03:16
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-04-15 10:41
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-526642.pdf8 pages
Itemised statement totalling $1837.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 43239 require precertification; no authorisation number on the claim.
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
Precertification required and absent.