CLM-2026-016434
Heritage Digestive Health Center, Gastroenterology. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-26.
Member
Resolved through the identity graph
- Member
- Sofia Garcia
- Member ID
- UHC-26354-32
- Date of birth
- 1962-08-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417341
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3669
- Coverage period
- 2024-12-01 to present
- Deductible
- $2,034.97 of $2,500.0081%
- Out-of-pocket maximum
- $3,738.02 of $10,000.0037%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 8235408357
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- none / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,815.00 | $998.25 | — | — | DeniedCO197 |
| Totals | $1,815.00 | $998.25 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-875364
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007780 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: OPTIONS-PPO (PPO), effective 2024-12-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Center2025-12-22 12:02
Patient seen for epigastric pain.
- SystemSystem: Claims system2026-01-26 02:53
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-01-26 08:41
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-875364.pdf7 pages
Itemised statement totalling $1815.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029679 | 2026-01-20 | Evergreen Reference Lab | $175.00 | Approved |
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
Precertification required and absent.