CLM-2026-031791
Summit Digestive Health Center, Gastroenterology. Service 2026-09-18 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Alice Hayes
- Member ID
- UHC-80765-96
- Date of birth
- 2000-06-23
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407883
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8233
- Coverage period
- 2025-06-01 to present
- Deductible
- $323.29 of $1,000.0032%
- Out-of-pocket maximum
- $1,315.85 of $3,000.0044%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 3142426964
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- PA2026970990 / 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 | $294.00 | $161.70 | $161.70 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,600.00 | $880.00 | $551.51 | $328.49 | Paid |
| Totals | $1,894.00 | $1,041.70 | $713.21 | $328.49 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-866357
- 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-015229 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-18: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026970990 on file for 45378. | |
| 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 Center2026-09-18 13:40
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026970990_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-09-18 to 2026-12-17.
- Itemized billitemized_PA-866357.pdf2 pages
Itemised statement totalling $1894.00 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-2026-008192 | 2026-05-23 | Heritage Community Hospital | $3,135.00 | Approved |
| CLM-2026-024672 | 2026-05-04 | Lakeside Clinical Laboratories | $109.00 | 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.