CLM-2026-034084
Meadow GI Associates, Gastroenterology. Service 2026-07-14 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Maria Stewart
- Member ID
- UHC-45508-52
- Date of birth
- 2006-12-26
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427277
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1150
- Coverage period
- 2023-10-01 to present
- Deductible
- $2,335.53 of $3,500.0067%
- Out-of-pocket maximum
- $1,543.71 of $14,000.0011%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 5848913971
- Location
- Los Angeles, CA · TIN 16-0400328
- Authorisation / referral
- PA2025057830 / 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 | $1,616.00 | $727.20 | $727.20 | $0.00 | Paid |
| Totals | $1,616.00 | $727.20 | $727.20 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-635061
- 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-022261 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-14: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025057830 on file for 43239. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Meadow GI Associates2026-07-14 17:48
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025057830_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-07-14 to 2026-10-12.
- Itemized billitemized_PA-635061.pdf5 pages
Itemised statement totalling $1616.00 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 13:43Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032661 | 2026-08-18 | Valley Primary Care Associates | $276.00 | Approved |
| CLM-2026-020294 | 2026-07-03 | Evergreen Medical Group | $3,240.00 | Needs review |
| CLM-2026-029458 | 2026-04-25 | Heritage Clinical Laboratories | $2,256.00 | 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.