CLM-2026-032125
Lakeside Digestive Health Center, Gastroenterology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-30.
Member
Resolved through the identity graph
- Member
- Judy Burns
- Member ID
- UHC-13174-98
- Date of birth
- 1980-12-09
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415700
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1473
- Coverage period
- 2021-06-01 to 2026-03-17
- Deductible
- $236.20 of $1,000.0024%
- Out-of-pocket maximum
- $286.51 of $3,000.0010%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 5154884873
- Network
- In network
- Rendering NPI
- 7280936189
- Location
- Denver, CO · TIN 37-4223782
- Authorisation / referral
- PA2025840729 / 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 | $206.00 | $113.30 | $113.30 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1 | $1,552.00 | $853.60 | $691.12 | $162.48 | Paid |
| Totals | $1,758.00 | $966.90 | $804.42 | $162.48 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-443699
- 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-007661 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: CHOICE-PLUS-PPO (PPO), effective 2021-06-01, terms 2026-03-17. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025840729 on file for 43239. | |
| Provider network | Pass | In-network provider Lakeside Digestive Health Center (5154884873). | |
| 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: Lakeside Digestive Health Center2025-12-31 14:42
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2025840729_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2025-12-31 to 2026-03-31.
- Itemized billitemized_PA-443699.pdf8 pages
Itemised statement totalling $1758.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021084 | 2026-08-13 | Pinecrest Bone and Joint Center | $9,739.00 | Denied |
| CLM-2026-031335 | 2026-08-08 | Meadow Bone and Joint Center | $236.00 | Denied |
| CLM-2026-018266 | 2026-03-23 | Sunrise Physical Therapy | $538.00 | Denied |
| CLM-2026-010350 | 2026-01-21 | Mesa Clinical Laboratories | $174.00 | 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.