CLM-2026-024097
Heritage Digestive Health Center, Gastroenterology. Service 2026-09-15 at outpatient hospital (POS 22). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Christine Wright
- Member ID
- UHC-27440-91
- Date of birth
- 1944-09-24
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-427297
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4938
- Coverage period
- 2022-07-01 to 2026-02-25
- Deductible
- $1,975.98 of $3,500.0056%
- Out-of-pocket maximum
- $2,494.59 of $10,500.0024%
- Copays
- office $30.00, specialist $60.00, 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
- 9458529770
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- PA2026376651 / REF105292
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 | $1,464.00 | $805.20 | — | — | DeniedCO27 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $360.00 | $198.00 | — | — | DeniedCO27 |
| Totals | $1,824.00 | $1,003.20 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-335573
- 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-042921 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-15 is after coverage terminated on 2026-02-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026376651 on file for 45378. | |
| 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 Center2026-09-15 18:39
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-18 06:53
Attachments
Documents received with the claim
- Prior auth letterPA2026376651_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-15 to 2026-12-14.
- Itemized billitemized_PA-335573.pdf8 pages
Itemised statement totalling $1824.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-15 is after coverage terminated on 2026-02-25.
Other claims for this member
Same resolved identity
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.