CLM-2026-015136
Harbor Digestive Health Center, Gastroenterology. Service 2026-07-28 at outpatient hospital (POS 22). Received 2026-09-11.
Member
Resolved through the identity graph
- Member
- Carl Mendez
- Member ID
- UHC-48311-13
- Date of birth
- 1990-10-19
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-400199
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0328
- Coverage period
- 2025-10-01 to present
- Deductible
- $1,215.81 of $1,500.0081%
- Out-of-pocket maximum
- $1,114.35 of $3,000.0037%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 4256828987
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2025288680 / REF178280
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 | $2,513.00 | $1,382.15 | $422.82 | $959.33 | Paid |
| Totals | $2,697.00 | $1,483.35 | $524.02 | $959.33 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-141127
- 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-024831 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-28: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025288680 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 Center2026-07-28 14:14
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2025288680_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-28 to 2026-10-26.
- Itemized billitemized_PA-141127.pdf4 pages
Itemised statement totalling $2697.00 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.