CLM-2026-033659
Riverside Digestive Health Center, Gastroenterology. Service 2026-08-21 at outpatient hospital (POS 22). Received 2026-08-27.
Member
Resolved through the identity graph
- Member
- Donald Carr
- Member ID
- UHC-61234-06
- Date of birth
- 2007-07-24
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-429685
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-3433
- Coverage period
- 2025-05-01 to present
- Deductible
- $204.62 of $500.0041%
- Out-of-pocket maximum
- $45.57 of $2,000.002%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 9435046427
- Network
- In network
- Rendering NPI
- 3127123289
- Location
- Atlanta, GA · TIN 82-1240911
- Authorisation / referral
- none / 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 | $271.00 | $149.05 | $149.05 | $0.00 | Paid |
| Totals | $271.00 | $149.05 | $149.05 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-222799
- 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-015250 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-21: N/A (PPO), effective 2025-05-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (9435046427). | |
| 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: Riverside Digestive Health Center2026-08-21 13:23
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-222799.pdf8 pages
Itemised statement totalling $271.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030177 | 2026-08-06 | Sunrise Digestive Health Center | $236.00 | Approved |
| CLM-2026-013882 | 2025-11-01 | Meadow Family Practice | $543.00 | Denied |
| CLM-2026-007970 | 2026-01-25 | Meadow Medical Group | $320.00 | 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.