CLM-2026-003608
Heritage Digestive Health Center, Gastroenterology. Service 2026-03-01 at outpatient hospital (POS 22). Received 2026-04-11.
Member
Resolved through the identity graph
- Member
- Robert Jordan
- Member ID
- UHC-77954-08
- Date of birth
- 1974-09-10
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-403609
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6745
- Coverage period
- 2021-05-01 to present
- Deductible
- $712.15 of $1,500.0047%
- Out-of-pocket maximum
- $1,824.99 of $4,500.0041%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 4917701417
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2026255733 / 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 | $2,379.00 | $1,308.45 | — | — | Review |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,848.00 | $1,016.40 | — | — | Review |
| Totals | $4,227.00 | $2,324.85 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-199995
- 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-008675 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-03-01: MEDICARE-ADV-A (MA), effective 2021-05-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026255733 on file for 43239, 45378. | |
| Provider network | Pass | In-network provider Heritage Digestive Health Center (4437349366). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with encounter for screening for malignant neoplasm of colon;”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Heritage Digestive Health Center2026-03-01 12:21
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-11 04:43
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-11 08:51
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026255733_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-01 to 2026-05-30.
- Itemized billitemized_PA-199995.pdf8 pages
Itemised statement totalling $4227.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with encounter for screening for malignant neoplasm of colon;”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013191 | 2026-03-12 | Lakeside Dermatology Clinic | $467.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.