CLM-2026-023431
Heritage GI Associates, Gastroenterology. Service 2026-03-17 at outpatient hospital (POS 22). Received 2026-03-31.
Member
Resolved through the identity graph
- Member
- Russell Wallace
- Member ID
- UHC-92159-02
- Date of birth
- 1958-10-21
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-423448
- Relationship
- Spouse, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6223
- Coverage period
- 2022-10-01 to present
- Deductible
- $239.16 of $3,500.007%
- Out-of-pocket maximum
- $5,853.85 of $14,000.0042%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 1186904995
- Location
- Phoenix, AZ · TIN 80-4628895
- Authorisation / referral
- PA2026105984 / REF162576
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 | $2,516.00 | $1,383.80 | $1,383.80 | $0.00 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $199.00 | $109.45 | $109.45 | $0.00 | Paid |
| Totals | $2,715.00 | $1,493.25 | $1,493.25 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-898408
- 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-021414 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-17: NAVIGATE-HMO (HMO), effective 2022-10-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026105984 on file for 43239. | |
| Provider network | Pass | In-network provider Heritage GI Associates (1403256369). | |
| 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 Associates2026-03-17 14:56
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2026105984_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-17 to 2026-06-15.
- Itemized billitemized_PA-898408.pdf6 pages
Itemised statement totalling $2715.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.