CLM-2026-030276
Canyon GI Associates, Gastroenterology. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Price Price
- Member ID
- UHC-27304-07
- Date of birth
- 1940-11-15
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-416578
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8487
- Coverage period
- 2022-06-01 to 2026-03-16
- Deductible
- $2,097.44 of $3,500.0060%
- Out-of-pocket maximum
- $640.74 of $10,500.006%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- 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
- 3591668546
- Location
- Minneapolis, MN · TIN 78-1003957
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $287.00 | $157.85 | — | — | DeniedCO27 |
| Totals | $287.00 | $157.85 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-459106
- 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-008940 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-03-16. 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 | No line requires precertification. | |
| 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 Associates2026-07-22 16:02
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-08-13 04:59
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-13 15:06
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-459106.pdf5 pages
Itemised statement totalling $287.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-03-16.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008890 | 2026-07-14 | Mesa Reference Lab | $96.00 | Denied |
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.