CLM-2026-003773
Heritage GI Associates, Gastroenterology. Service 2026-06-15 at outpatient hospital (POS 22). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Brandon Holmes
- Member ID
- UHC-99673-23
- Date of birth
- 1948-05-27
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-416609
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-2349
- Coverage period
- 2022-06-01 to present
- Deductible
- $908.80 of $2,500.0036%
- Out-of-pocket maximum
- $636.02 of $7,500.008%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 9830465313
- Location
- Phoenix, AZ · TIN 80-4628895
- Authorisation / referral
- PA2025535268 / 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 | $2,211.00 | $1,216.05 | — | — | DeniedCO18 |
| Totals | $2,211.00 | $1,216.05 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-371134
- 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-034567 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-15: N/A (PPO), effective 2022-06-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-003772: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | Authorisation PA2025535268 on file for 45378. | |
| Provider network | Pass | In-network provider Heritage GI Associates (1403256369). | |
| 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 Associates2026-06-15 11:16
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-20 01:52
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 letterPA2025535268_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-06-15 to 2026-09-13.
- Itemized billitemized_PA-371134.pdf2 pages
Itemised statement totalling $2211.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-003772: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003772 | 2026-06-15 | Heritage GI Associates | $2,211.00 | Approved |
| CLM-2026-013632 | 2026-04-27 | Unity Cardiovascular Associates | $597.00 | 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.