CLM-2026-030765
Summit Digestive Health Center, Gastroenterology. Service 2026-09-11 at outpatient hospital (POS 22). Received 2026-09-16.
Member
Resolved through the identity graph
- Member
- Benjamin Gibson
- Member ID
- UHC-15397-39
- Date of birth
- 1990-11-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-420780
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4421
- Coverage period
- 2022-01-01 to present
- Deductible
- $98.27 of $500.0020%
- Out-of-pocket maximum
- $692.44 of $1,500.0046%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 3949823827
- Location
- Nashville, TN · TIN 32-9600100
- 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 | $182.00 | $100.10 | $100.10 | $0.00 | Paid |
| Totals | $182.00 | $100.10 | $100.10 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-475360
- 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-005934 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-11: NAVIGATE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 5 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 Summit Digestive Health Center (1126576986). | |
| 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: Summit Digestive Health Center2026-09-11 17:09
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-475360.pdf4 pages
Itemised statement totalling $182.00 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-2026-007921 | 2026-06-30 | Meadow Bone and Joint Center | $195.00 | Approved |
| CLM-2026-017320 | 2025-12-18 | Evergreen Dermatology Clinic | $156.00 | 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.