CLM-2026-033343
Unity Digestive Health Center, Gastroenterology. Service 2026-07-03 at outpatient hospital (POS 22). Received 2026-08-06.
Member
Resolved through the identity graph
- Member
- Gerald Miller
- Member ID
- UHC-84890-95
- Date of birth
- 1983-04-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-403822
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1300
- Coverage period
- 2024-04-01 to present
- Deductible
- $751.26 of $1,500.0050%
- Out-of-pocket maximum
- $824.21 of $3,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7402154927
- Network
- In network
- Rendering NPI
- 8221203119
- Location
- Denver, CO · TIN 51-9644882
- Authorisation / referral
- PA2025489782 / 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 | $2,479.00 | $1,363.45 | $810.21 | $553.24 | Paid |
| Totals | $2,479.00 | $1,363.45 | $810.21 | $553.24 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-648467
- 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-001149 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-03: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025489782 on file for 45378. | |
| Provider network | Pass | In-network provider Unity Digestive Health Center (7402154927). | |
| 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 Center2026-07-03 14:33
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025489782_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-07-03 to 2026-10-01.
- Itemized billitemized_PA-648467.pdf4 pages
Itemised statement totalling $2479.00 across 1 line.
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-2026-029718 | 2026-04-27 | Summit Counseling Center | $557.00 | Approved |
| CLM-2026-024226 | 2025-12-08 | Cornerstone Reference Lab | $195.00 | Denied |
| CLM-2026-016227 | 2025-11-22 | Desert Regional Medical Center | $213.00 | Needs review |
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.