CLM-2026-002113
Heritage GI Associates, Gastroenterology. Service 2026-08-25 at outpatient hospital (POS 22). Received 2026-09-02.
Member
Resolved through the identity graph
- Member
- Judy Waktins
- Member ID
- none on golden record
- Date of birth
- 1973-04-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424119
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-8024
- Coverage period
- 2021-03-01 to present
- Deductible
- $2.54 of $1,000.000%
- Out-of-pocket maximum
- $232.67 of $2,000.0012%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 8757563563
- Location
- Tempe, AZ · TIN 81-8461121
- 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,889.00 | $1,038.95 | — | — | DeniedCO197 |
| Totals | $1,889.00 | $1,038.95 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-740052
- 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-043213 (provisional, link confidence 1.00). | |
| Eligibility | Note | Active on 2026-08-25: MEDICARE-ADV-A (MA), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Heritage GI Associates (8459983820). | |
| 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: Heritage GI Associates2026-08-25 15:22
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-02 03:09
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-740052.pdf2 pages
Itemised statement totalling $1889.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Active on 2026-08-25: MEDICARE-ADV-A (MA), effective 2021-03-01. Coverage found by name and date of birth because the claim carried no usable member ID. Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.