CLM-2026-031695
Mesa GI Associates, Gastroenterology. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Valentina Valdez
- Member ID
- UHC-40345-86
- Date of birth
- 1957-12-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417110
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5050
- Coverage period
- 2025-07-01 to 2026-01-17
- Deductible
- $1,337.25 of $1,500.0089%
- Out-of-pocket maximum
- $2,937.31 of $6,000.0049%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7557205672
- Network
- In network
- Rendering NPI
- 1055464162
- Location
- Phoenix, AZ · TIN 12-8480573
- Authorisation / referral
- PA2025148458 / REF235124
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 | $1,998.00 | $1,098.90 | — | — | DeniedCO27 |
| Totals | $1,998.00 | $1,098.90 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-789558
- 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-032870 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-22 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025148458 on file for 45378. | |
| Provider network | Pass | In-network provider Mesa GI Associates (7557205672). | |
| 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: Mesa GI Associates2026-07-22 09:54
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-27 05:11
Attachments
Documents received with the claim
- Prior auth letterPA2025148458_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-22 to 2026-10-20.
- Itemized billitemized_PA-789558.pdf6 pages
Itemised statement totalling $1998.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-22 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031235 | 2026-05-10 | Meadow Family Practice | $280.00 | 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.