CLM-2026-033897
Riverside Digestive Health Center, Gastroenterology. Service 2026-01-07 at outpatient hospital (POS 22). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Carlos Bailey
- Member ID
- UHC-97041-61
- Date of birth
- 1965-04-06
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429247
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7462
- Coverage period
- 2025-09-01 to present
- Deductible
- $311.95 of $1,000.0031%
- Out-of-pocket maximum
- $920.28 of $2,000.0046%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 8834777772
- Network
- In network
- Rendering NPI
- 6964359643
- Location
- Tempe, AZ · TIN 41-1081863
- Authorisation / referral
- PA2025685926 / 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 | $209.00 | $114.95 | $114.95 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $1,442.00 | $793.10 | $617.10 | $176.00 | Paid |
| Totals | $1,651.00 | $908.05 | $732.05 | $176.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-220156
- 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-013334 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-07: MEDICARE-ADV-B (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025685926 on file for 43239. | |
| Provider network | Pass | In-network provider Riverside Digestive Health Center (8834777772). | |
| 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 Center2026-01-07 14:10
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2025685926_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-07 to 2026-04-07.
- Itemized billitemized_PA-220156.pdf2 pages
Itemised statement totalling $1651.00 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.