CLM-2026-017625
Heritage GI Associates, Gastroenterology. Service 2026-06-23 at outpatient hospital (POS 22). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Karen Campbell
- Member ID
- UHC-16103-42
- Date of birth
- 1942-01-28
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-423180
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9573
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,508.09 of $2,500.0060%
- Out-of-pocket maximum
- $1,223.97 of $5,000.0024%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 6081087218
- Location
- Tempe, AZ · TIN 81-8461121
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $239.00 | $131.45 | — | — | DeniedCO197 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $1,600.00 | $880.00 | — | — | DeniedCO197 |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $2,455.00 | $1,350.25 | — | — | DeniedCO197 |
| Totals | $4,294.00 | $2,361.70 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-817365
- 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-026112 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: MEDICARE-ADV-A (MA), effective 2021-11-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239, 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Heritage GI Associates (8459983820). | |
| 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 GI Associates2026-06-23 13:24
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-23 05:01
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-817365.pdf4 pages
Itemised statement totalling $4294.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239, 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002794 | 2026-08-03 | Northgate Clinical Laboratories | $144.00 | 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.