CLM-2026-018409
Heritage Digestive Health Center, Gastroenterology. Service 2026-02-16 at outpatient hospital (POS 22). Received 2026-03-24.
Member
Resolved through the identity graph
- Member
- Billy Lewis
- Member ID
- UHC-05923-12
- Date of birth
- 2001-11-16
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-424230
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-7977
- Coverage period
- 2024-08-01 to present
- Deductible
- $268.04 of $1,500.0018%
- Out-of-pocket maximum
- $812.62 of $3,000.0027%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 6282286957
- 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,306.00 | $718.30 | — | — | DeniedCO197 |
| Totals | $1,306.00 | $718.30 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-989731
- 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-021762 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-16: - (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 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 Center2026-02-16 09:36
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-03-24 05:55
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-03-24 12:31
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-989731.pdf8 pages
Itemised statement totalling $1306.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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.