CLM-2026-033380
Summit Digestive Health Center, Gastroenterology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Timothy Stevens
- Member ID
- UHC-96853-72
- Date of birth
- 2003-10-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-426164
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3541
- Coverage period
- 2024-01-01 to present
- Deductible
- $2,016.19 of $2,500.0081%
- Out-of-pocket maximum
- $4,918.51 of $10,000.0049%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 1126576986
- Network
- In network
- Rendering NPI
- 4282543915
- Location
- Nashville, TN · TIN 32-9600100
- Authorisation / referral
- PA2025249871 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,524.00 | $1,388.20 | $664.69 | $723.51 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,536.00 | $844.80 | $168.96 | $675.84 | Paid |
| Totals | $4,060.00 | $2,233.00 | $833.65 | $1,399.35 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-656623
- 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-008164 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: NAVIGATE-HMO (HMO), effective 2024-01-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025249871 on file for 43239, 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 Center2026-01-12 18:34
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025249871_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-12 to 2026-04-12.
- Itemized billitemized_PA-656623.pdf7 pages
Itemised statement totalling $4060.00 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
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.