CLM-2026-013241
Harbor Digestive Health Center, Gastroenterology. Service 2026-01-09 at outpatient hospital (POS 22). Received 2026-01-27.
Member
Resolved through the identity graph
- Member
- Bruce Johnston
- Member ID
- UHC-32734-85
- Date of birth
- 1957-08-10
- Identity
- Verified6 records, confidence 0.87
- Claim record
- CLMCLM-402138
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7041
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,948.85 of $2,500.0078%
- Out-of-pocket maximum
- $2,481.96 of $5,000.0050%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 2408482745
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2025931568 / 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 | $1,307.00 | $718.85 | $567.92 | $150.93 | Paid |
| Totals | $1,307.00 | $718.85 | $567.92 | $150.93 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-464706
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008126 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-01-09: SELECT-EPO (EPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025931568 on file for 43239. | |
| 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 Center2026-01-09 15:16
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025931568_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-09 to 2026-04-09.
- Itemized billitemized_PA-464706.pdf6 pages
Itemised statement totalling $1307.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022976 | 2026-05-27 | Evergreen Primary Care Associates | $371.00 | Approved |
| CLM-2026-012582 | 2026-03-30 | Desert Internal Medicine Associates | $260.00 | Approved |
| CLM-2026-011929 | 2026-03-13 | Northgate Bone and Joint Center | $1,168.00 | Denied |
| CLM-2026-025838 | 2026-02-12 | Pinecrest Diagnostic Imaging | $444.00 | Needs review |
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.