CLM-2026-031311
Riverside Digestive Health Center, Gastroenterology. Service 2026-09-03 at outpatient hospital (POS 22). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Juan Munoz
- Member ID
- UHC-06071-85
- Date of birth
- 1945-07-17
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430452
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4312
- Coverage period
- 2021-08-01 to present
- Deductible
- $2,210.11 of $3,500.0063%
- Out-of-pocket maximum
- $2,920.07 of $14,000.0021%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 6559286680
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- PA2026532565 / 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 | $1,885.00 | $1,036.75 | — | — | PendedIDQ |
| Totals | $1,885.00 | $1,036.75 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-689187
- 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 | Fail | IDQ | Member record is in open steward case CASE-002618; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-09-03: MEDICARE-ADV-A (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026532565 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 Center2026-09-03 15:08
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2026532565_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-03 to 2026-12-02.
- Itemized billitemized_PA-689187.pdf3 pages
Itemised statement totalling $1885.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002618; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.