CLM-2026-022561
Harbor Digestive Health Center, Gastroenterology. Service 2026-06-22 at outpatient hospital (POS 22). Received 2026-08-04.
Member
Resolved through the identity graph
- Member
- Jacob Vasquez
- Member ID
- UHC-00788-94
- Date of birth
- 1985-05-07
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-411230
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9204
- Coverage period
- 2025-06-01 to present
- Deductible
- $1,137.56 of $1,500.0076%
- Out-of-pocket maximum
- $950.40 of $3,000.0032%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 6141454416
- Location
- Tempe, AZ · TIN 89-3478747
- 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,621.00 | $891.55 | — | — | DeniedCO197 |
| Totals | $1,621.00 | $891.55 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-342150
- 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-021300 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-22: SELECT-EPO (EPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Harbor Digestive Health Center (7922422671). | |
| 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: Harbor Digestive Health Center2026-06-22 15:56
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-04 02:19
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-342150.pdf3 pages
Itemised statement totalling $1621.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025716 | 2026-07-15 | Pinecrest GI Associates | $338.00 | Approved |
| CLM-2026-032384 | 2026-05-24 | Harbor Primary Care Associates | $240.00 | Denied |
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.