CLM-2026-018263
Heritage Digestive Health Center, Gastroenterology. Service 2026-06-23 at outpatient hospital (POS 22). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Steven Brooks
- Member ID
- UHC-72425-74
- Date of birth
- 1991-05-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-416193
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5556
- Coverage period
- 2025-11-01 to present
- Deductible
- $296.40 of $2,500.0012%
- Out-of-pocket maximum
- $2,741.87 of $7,500.0037%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 9240316437
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $210.00 | $115.50 | $115.50 | $0.00 | Paid |
| Totals | $210.00 | $115.50 | $115.50 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-894816
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020386 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-06-23 13:56
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-894816.pdf3 pages
Itemised statement totalling $210.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012577 | 2026-09-25 | Pinecrest Cardiovascular Associates | $7,698.00 | Denied |
| CLM-2026-022696 | 2026-09-21 | Riverside Bone and Joint Center | $35,439.00 | Needs review |
| CLM-2026-028215 | 2026-07-19 | Heritage Digestive Health Center | $229.00 | 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.