CLM-2026-004063
Harbor Digestive Health Center, Gastroenterology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Jennifer West
- Member ID
- UHC-32000-97
- Date of birth
- 1962-05-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417990
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4875
- Coverage period
- 2024-05-01 to 2026-01-09
- Deductible
- $1,165.28 of $3,500.0033%
- Out-of-pocket maximum
- $276.09 of $10,500.003%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 2599979517
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2025125980 / 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 | $2,020.00 | $1,111.00 | $1,111.00 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1,2 | $1,531.00 | $842.05 | $842.05 | $0.00 | Paid |
| Totals | $3,551.00 | $1,953.05 | $1,953.05 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-407679
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011582 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-08: CHOICE-PLUS-PPO (PPO), effective 2024-05-01, terms 2026-01-09. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025125980 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 Center2026-01-08 15:57
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025125980_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-407679.pdf3 pages
Itemised statement totalling $3551.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean 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.