CLM-2026-013158
Heritage GI Associates, Gastroenterology. Service 2026-01-17 at outpatient hospital (POS 22). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Frances Lawson
- Member ID
- UHC-42785-62
- Date of birth
- 1986-07-22
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-429781
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group UNKNOWN
- Coverage period
- 2023-07-01 to present
- Deductible
- $711.81 of $1,000.0071%
- Out-of-pocket maximum
- $14.37 of $2,000.001%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 6733756111
- Location
- Phoenix, AZ · TIN 80-4628895
- Authorisation / referral
- PA2026331527 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $184.00 | $101.20 | $101.20 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $2,599.00 | $1,429.45 | $435.48 | $993.97 | Paid |
| Totals | $2,783.00 | $1,530.65 | $536.68 | $993.97 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-740493
- 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-007191 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-01-17: UNKNOWN (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026331527 on file for 43239. | |
| 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 Associates2026-01-17 14:52
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026331527_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-17 to 2026-04-17.
- Itemized billitemized_PA-740493.pdf3 pages
Itemised statement totalling $2783.00 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.