CLM-2026-021539
Heritage GI Associates, Gastroenterology. Service 2026-04-29 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Christian Marshall
- Member ID
- UHC-58093-69
- Date of birth
- 1994-01-04
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-408449
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3414
- Coverage period
- 2024-01-01 to 2026-04-01
- Deductible
- $133.50 of $500.0027%
- Out-of-pocket maximum
- $401.33 of $1,000.0040%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 8894146611
- Location
- Tempe, AZ · TIN 81-8461121
- Authorisation / referral
- PA2026575105 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,935.00 | $1,064.25 | — | — | DeniedCO27 |
| Totals | $1,935.00 | $1,064.25 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-776249
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002137 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-29 is after coverage terminated on 2026-04-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026575105 on file for 45378. | |
| Provider network | Pass | In-network provider Heritage GI Associates (8459983820). | |
| 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 GI Associates2026-04-29 10:32
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-06-12 05:21
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-12 10:26
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026575105_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-04-29 to 2026-07-28.
- Itemized billitemized_PA-776249.pdf5 pages
Itemised statement totalling $1935.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-29 is after coverage terminated on 2026-04-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025663 | 2026-08-28 | Summit Community Hospital | $769.00 | Denied |
| CLM-2026-011968 | 2026-01-04 | Summit Reference Lab | $137.00 | Approved |
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
Service after coverage termination.