CLM-2026-023727
Heritage GI Associates, Gastroenterology. Service 2026-04-15 at office (POS 11). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Steven Price
- Member ID
- UHC-78273-41
- Date of birth
- 1939-01-16
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421210
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3400
- Coverage period
- 2022-10-01 to present
- Deductible
- $211.13 of $1,500.0014%
- Out-of-pocket maximum
- $37.34 of $4,500.001%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 9563244208
- Location
- Phoenix, AZ · TIN 80-4628895
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $237.00 | $146.94 | — | — | DeniedCO18 |
| Totals | $237.00 | $146.94 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-897344
- 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-011065 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-15: OPTIONS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 61 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-023726: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-04-15 15:56
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-15 04:15
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-023726: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032212 | 2026-06-22 | Northgate Internal Medicine Associates | $291.00 | Approved |
| CLM-2026-002790 | 2026-06-04 | Unity Counseling Center | $469.00 | Approved |
| CLM-2026-023726 | 2026-04-15 | Heritage GI Associates | $237.00 | 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
Exact duplicate of an earlier submission.