CLM-2026-034091
Meadow GI Associates, Gastroenterology. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-02-10.
Member
Resolved through the identity graph
- Member
- Arjun Vega
- Member ID
- none on golden record
- Date of birth
- 2004-09-06
- Identity
- Verified2 records, confidence 0.93
- Claim record
- CLMCLM-408430
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-2508
- Coverage period
- 2023-04-01 to present
- Deductible
- $2,624.42 of $3,500.0075%
- Out-of-pocket maximum
- $688.65 of $10,500.007%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 7747243401
- Network
- Out of network
- Rendering NPI
- 2133781601
- Location
- Los Angeles, CA · TIN 16-0400328
- 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 | $326.00 | $146.70 | $146.70 | $0.00 | Paid |
| Totals | $326.00 | $146.70 | $146.70 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-516860
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011868 (verified, link confidence 0.93). | |
| Eligibility | Note | Active on 2025-12-29: MEDICARE-ADV-B (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 43 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 | 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 Associates2025-12-29 18:48
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-516860.pdf5 pages
Itemised statement totalling $326.00 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 12:44Eligibility: Active on 2025-12-29: MEDICARE-ADV-B (MA), effective 2023-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider 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-2026-028895 | 2026-05-06 | Canyon Reference Lab | $121.00 | 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.