CLM-2026-013669
Heritage Digestive Health Center, Gastroenterology. Service 2026-04-22 at outpatient hospital (POS 22). Received 2026-05-06.
Member
Resolved through the identity graph
- Member
- Matthew Day
- Member ID
- UHC-65445-38
- Date of birth
- 1971-04-04
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-408613
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4562
- Coverage period
- 2021-11-01 to 2026-01-02
- Deductible
- $1,087.00 of $3,500.0031%
- Out-of-pocket maximum
- $1,109.73 of $10,500.0011%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 7114359327
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- none / REF370277
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 | $263.00 | $144.65 | — | — | DeniedCO27 |
| Totals | $263.00 | $144.65 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-980359
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001601 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-22 is after coverage terminated on 2026-01-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage Digestive Health Center (4437349366). | |
| 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 Digestive Health Center2026-04-22 17:55
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-06 03:52
Attachments
Documents received with the claim
- Itemized billitemized_PA-980359.pdf6 pages
Itemised statement totalling $263.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-22 is after coverage terminated on 2026-01-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020836 | 2026-09-11 | Desert Medical Group | $568.00 | Denied |
| CLM-2026-016714 | 2026-09-16 | Canyon Primary Care Associates | $452.00 | Denied |
| CLM-2026-020179 | 2026-08-12 | Sunrise GI Associates | $305.00 | Denied |
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
Service after coverage termination.