CLM-2026-021155
Heritage Digestive Health Center, Gastroenterology. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-04-20.
Member
Resolved through the identity graph
- Member
- Carl Park
- Member ID
- UHC-65013-19
- Date of birth
- 1963-01-14
- Identity
- Verified7 records, confidence 1.00
- Claim record
- CLMCLM-413292
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4467
- Coverage period
- 2024-02-01 to present
- Deductible
- $187.63 of $3,500.005%
- Out-of-pocket maximum
- $4,813.23 of $10,500.0046%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 4578575241
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2025052511 / 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 | $2,367.00 | $1,301.85 | $1,301.85 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | 25 | 1 | 1 | $353.00 | $194.15 | $194.15 | $0.00 | Paid |
| Totals | $2,720.00 | $1,496.00 | $1,496.00 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-545230
- 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-015163 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-08: MEDICARE-ADV-B (MA), effective 2024-02-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025052511 on file for 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 Center2026-03-08 16:03
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025052511_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-08 to 2026-06-06.
- Itemized billitemized_PA-545230.pdf6 pages
Itemised statement totalling $2720.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026224 | 2026-04-01 | Meadow Physical Therapy | $190.00 | Approved |
| CLM-2026-021014 | 2026-02-19 | Mesa Diabetes Center | $343.00 | Approved |
| CLM-2026-024547 | 2026-01-18 | Pinecrest Diagnostic Imaging | $3,775.00 | Denied |
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.