CLM-2026-017809
Heritage GI Associates, Gastroenterology. Service 2026-04-14 at outpatient hospital (POS 22). Received 2026-04-28.
Member
Resolved through the identity graph
- Member
- Angela Morgan
- Member ID
- UHC-21095-73
- Date of birth
- 1974-12-15
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-426900
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8819
- Coverage period
- 2024-09-01 to present
- Deductible
- $1,505.94 of $2,500.0060%
- Out-of-pocket maximum
- $3,497.34 of $7,500.0047%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 1042592380
- Location
- Tempe, AZ · TIN 81-8461121
- Authorisation / referral
- PA2025900613 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,620.00 | $1,441.00 | — | — | Review |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $210.00 | $115.50 | — | — | Review |
| Totals | $2,830.00 | $1,556.50 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-721682
- 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-009518 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-14: CHOICE-PLUS-PPO (PPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025900613 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage GI Associates (8459983820). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Associates2026-04-14 10:44
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-04-28 01:38
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025900613_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-14 to 2026-07-13.
- Itemized billitemized_PA-721682.pdf7 pages
Itemised statement totalling $2830.00 across 2 lines.
- Medical recordrecords_PA-721682.pdf21 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016026 | 2026-01-16 | Northgate Medical Group | $274.00 | Needs review |
| CLM-2026-016025 | 2026-01-16 | Northgate Medical Group | $274.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.