CLM-2026-031251
Unity Digestive Health Center, Gastroenterology. Service 2026-04-04 at outpatient hospital (POS 22). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Mariana Peterson
- Member ID
- UHC-91604-29
- Date of birth
- 1998-12-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423868
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9145
- Coverage period
- 2022-05-01 to present
- Deductible
- $420.19 of $500.0084%
- Out-of-pocket maximum
- $257.74 of $1,000.0026%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9735187566
- Network
- In network
- Rendering NPI
- 9021496382
- Location
- Austin, TX · TIN 73-9134731
- 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,017.00 | $1,109.35 | — | — | DeniedCO197 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $209.00 | $114.95 | — | — | DeniedCO197 |
| Totals | $2,226.00 | $1,224.30 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-957943
- 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-018242 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-04: OPTIONS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Digestive Health Center (9735187566). | |
| 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: Unity Digestive Health Center2026-04-04 11:09
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-06 02:17
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-06 10:53
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-957943.pdf7 pages
Itemised statement totalling $2226.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021720 | 2026-02-06 | Pinecrest GI Associates | $3,568.00 | Approved |
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.