CLM-2026-020301
Heritage Digestive Health Center, Gastroenterology. Service 2026-07-05 at outpatient hospital (POS 22). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Jerry Torres
- Member ID
- UHC-90769-88
- Date of birth
- 1947-01-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431565
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2344
- Coverage period
- 2023-07-01 to present
- Deductible
- $401.73 of $3,500.0011%
- Out-of-pocket maximum
- $5,528.40 of $14,000.0039%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- 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
- 8357115202
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2025763996 / 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 | $225.00 | $123.75 | $123.75 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,603.00 | $881.65 | $881.65 | $0.00 | Paid |
| 3 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $2,317.00 | $1,274.35 | $1,274.35 | $0.00 | Paid |
| Totals | $4,145.00 | $2,279.75 | $2,279.75 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-259810
- 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-034944 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: OPTIONS-PPO (PPO), effective 2023-07-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025763996 on file for 45378, 43239. | |
| 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 Center2026-07-05 13:16
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025763996_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-05 to 2026-10-03.
- Itemized billitemized_PA-259810.pdf2 pages
Itemised statement totalling $4145.00 across 3 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-2026-020321 | 2026-05-30 | Mesa Internal Medicine Associates | $78.00 | Needs review |
| CLM-2026-020320 | 2026-05-30 | Mesa Internal Medicine Associates | $78.00 | 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.