CLM-2026-034172
Canyon GI Associates, Gastroenterology. Service 2026-02-21 at outpatient hospital (POS 22). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Ethan Welch
- Member ID
- UHC-61196-41
- Date of birth
- 1941-06-23
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-424823
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8880
- Coverage period
- 2025-06-01 to present
- Deductible
- $3,135.73 of $3,500.0090%
- Out-of-pocket maximum
- $810.61 of $10,500.008%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8906815153
- Network
- In network
- Rendering NPI
- 9891654623
- Location
- Minneapolis, MN · TIN 78-1003957
- Authorisation / referral
- PA2025391540 / REF435827
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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,566.00 | $1,411.30 | — | — | DeniedCO18 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $2,022.00 | $1,112.10 | — | — | DeniedCO18 |
| Totals | $4,588.00 | $2,523.40 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-730131
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017947 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-02-21: NAVIGATE-HMO (HMO), effective 2025-06-01. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-034171: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025391540 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Canyon GI Associates (8906815153). | |
| 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: Canyon GI Associates2026-02-21 14:03
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-04 02:40
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Prior auth letterPA2025391540_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-21 to 2026-05-22.
- Itemized billitemized_PA-730131.pdf7 pages
Itemised statement totalling $4588.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-034171: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034171 | 2026-02-21 | Canyon GI Associates | $4,588.00 | 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
Exact duplicate of an earlier submission.