CLM-2026-001131
Harbor Digestive Health Center, Gastroenterology. Service 2026-04-12 at outpatient hospital (POS 22). Received 2026-05-18.
Member
Resolved through the identity graph
- Member
- Larry Hall
- Member ID
- UHC-42998-10
- Date of birth
- 1976-01-12
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406262
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1858
- Coverage period
- 2023-12-01 to present
- Deductible
- $764.55 of $2,500.0031%
- Out-of-pocket maximum
- $538.01 of $7,500.007%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 5510761294
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2026275655 / 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 | $2,507.00 | $1,378.85 | $1,378.85 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $1,670.00 | $918.50 | $468.98 | $449.52 | Paid |
| Totals | $4,177.00 | $2,297.35 | $1,847.83 | $449.52 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-797548
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003025 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-12: NULL (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026275655 on file for 43239, 45378. | |
| Provider network | Pass | In-network provider Harbor Digestive Health Center (7922422671). | |
| 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: Harbor Digestive Health Center2026-04-12 17:29
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2026275655_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-04-12 to 2026-07-11.
- Itemized billitemized_PA-797548.pdf3 pages
Itemised statement totalling $4177.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.