CLM-2026-007925
Heritage GI Associates, Gastroenterology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Cynthia Green
- Member ID
- UHC-66762-67
- Date of birth
- 1979-06-21
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414704
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6707
- Coverage period
- 2025-12-01 to present
- Deductible
- $1,938.86 of $3,500.0055%
- Out-of-pocket maximum
- $5,090.78 of $14,000.0036%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 3079945812
- Location
- Tempe, AZ · TIN 81-8461121
- Authorisation / referral
- PA2026842037 / 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 | $1,726.00 | $949.30 | $949.30 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $341.00 | $187.55 | $187.55 | $0.00 | Paid |
| Totals | $2,067.00 | $1,136.85 | $1,136.85 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-738185
- 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-011352 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: MEDICARE-ADV-A (MA), effective 2025-12-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026842037 on file for 43239. | |
| 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 Associates2025-12-30 16:05
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026842037_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-738185.pdf5 pages
Itemised statement totalling $2067.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021593 | 2026-03-05 | Meadow Reference Lab | $75.00 | Approved |
| CLM-2026-001814 | 2026-03-13 | Evergreen Primary Care Associates | $378.00 | Approved |
| CLM-2026-009508 | 2026-02-05 | Lakeside Reference Lab | $53.00 | Approved |
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.