CLM-2026-009640
Heritage GI Associates, Gastroenterology. Service 2026-07-17 at outpatient hospital (POS 22). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Henry Holmes
- Member ID
- UHC-19695-21
- Date of birth
- 1999-05-23
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-414193
- Relationship
- Child, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group -
- Coverage period
- 2021-09-01 to present
- Deductible
- $941.52 of $2,500.0038%
- Out-of-pocket maximum
- $380.38 of $5,000.008%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 5642976760
- 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 | $1,578.00 | $867.90 | — | — | DeniedCO197 |
| Totals | $1,578.00 | $867.90 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-195768
- 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-039441 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-17: - (PPO), effective 2021-09-01. | |
| 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 Associates2026-07-17 09:22
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-07-25 05:24
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-25 16:47
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-195768.pdf7 pages
Itemised statement totalling $1578.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020361 | 2026-06-22 | Unity Medical Group | $50.00 | 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
Precertification required and absent.