CLM-2026-014101
Heritage Digestive Health Center, Gastroenterology. Service 2026-01-13 at outpatient hospital (POS 22). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Isabella Gomez
- Member ID
- UHC-25379-25
- Date of birth
- 1977-02-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407036
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6433
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,470.83 of $3,500.0042%
- Out-of-pocket maximum
- $10.13 of $7,000.000%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 8096636930
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2025534787 / REF180703
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 | $2,052.00 | $1,128.60 | $1,128.60 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | 25 | 1 | 2 | $2,260.00 | $1,243.00 | $1,003.30 | $239.70 | Paid |
| Totals | $4,312.00 | $2,371.60 | $2,131.90 | $239.70 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-582794
- 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-010990 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-13: NAVIGATE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025534787 on file for 43239, 45378. | |
| 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 Center2026-01-13 16:06
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025534787_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-13 to 2026-04-13.
- Itemized billitemized_PA-582794.pdf2 pages
Itemised statement totalling $4312.00 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-2026-003369 | 2026-08-23 | Sunrise Cardiovascular Associates | $548.00 | Approved |
| CLM-2026-007066 | 2026-05-15 | Evergreen Dermatology Clinic | $578.00 | Approved |
| CLM-2026-015199 | 2026-01-13 | Mesa Physical Therapy | $152.00 | 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.