CLM-2026-034029
Mesa GI Associates, Gastroenterology. Service 2026-06-24 at outpatient hospital (POS 22). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Ryan Li
- Member ID
- UHC-59343-89
- Date of birth
- 1963-09-10
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-421099
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6378
- Coverage period
- 2022-03-01 to present
- Deductible
- $3,106.42 of $3,500.0089%
- Out-of-pocket maximum
- $4,021.66 of $14,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7557205672
- Network
- In network
- Rendering NPI
- 9174696820
- Location
- Phoenix, AZ · TIN 12-8480573
- 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 | $352.00 | $193.60 | — | — | DeniedCO29 |
| Totals | $352.00 | $193.60 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-226948
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022944 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-24: CHOICE-PLUS-PPO (PPO), effective 2022-03-01. | |
| Timely filing | Fail | CO29 | Received 112 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Mesa GI Associates (7557205672). | |
| 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: Mesa GI Associates2026-06-24 16:11
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-14 00:15
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-226948.pdf3 pages
Itemised statement totalling $352.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018872 | 2026-07-05 | Lakeside Medical Group | $288.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.