CLM-2026-030356
Riverside Digestive Health Center, Gastroenterology. Service 2025-12-28 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Eric Castro
- Member ID
- UHC-08239-66
- Date of birth
- 1968-04-02
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408477
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8348
- Coverage period
- 2023-10-01 to 2026-04-20
- Deductible
- $1,515.32 of $2,500.0061%
- Out-of-pocket maximum
- $3,233.62 of $7,500.0043%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 4035064797
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026137648 / REF432399
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 | $1,721.00 | $946.55 | $946.55 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $291.00 | $160.05 | $62.51 | $97.54 | Paid |
| Totals | $2,012.00 | $1,106.60 | $1,009.06 | $97.54 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-711282
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004267 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-28: CORE-HMO (HMO), effective 2023-10-01, terms 2026-04-20. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026137648 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 Center2025-12-28 11:14
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026137648_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2025-12-28 to 2026-03-28.
- Itemized billitemized_PA-711282.pdf5 pages
Itemised statement totalling $2012.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033432 | 2026-04-28 | Pinecrest Clinical Laboratories | $124.00 | Denied |
| CLM-2026-025371 | 2026-05-01 | Sunrise Imaging Center | $410.00 | Denied |
| CLM-2026-015676 | 2026-03-07 | Desert Internal Medicine Associates | $323.00 | 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.