CLM-2026-018137
Heritage Digestive Health Center, Gastroenterology. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Hiroshi Lawrence
- Member ID
- UHC-54967-01
- Date of birth
- 1943-01-16
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-411980
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0239
- Coverage period
- 2023-06-01 to present
- Deductible
- $862.96 of $1,500.0058%
- Out-of-pocket maximum
- $665.73 of $6,000.0011%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 7085837103
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2025766770 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,460.00 | $803.00 | $670.23 | $132.77 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,122.00 | $1,167.10 | $233.42 | $933.68 | Paid |
| Totals | $3,582.00 | $1,970.10 | $903.65 | $1,066.45 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-728676
- 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-009199 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-29: CHOICE-PLUS-PPO (PPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025766770 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 Center2025-12-29 12:01
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025766770_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-728676.pdf8 pages
Itemised statement totalling $3582.00 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-2026-013548 | 2026-02-10 | Evergreen Family Practice | $326.00 | 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.