CLM-2026-025358
Heritage GI Associates, Gastroenterology. Service 2026-03-14 at outpatient hospital (POS 22). Received 2026-04-04.
Member
Resolved through the identity graph
- Member
- Julia Dean
- Member ID
- UHC-21980-71
- Date of birth
- 1987-06-17
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-424692
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-7190
- Coverage period
- 2022-05-01 to 2026-02-11
- Deductible
- $244.72 of $500.0049%
- Out-of-pocket maximum
- $379.40 of $1,000.0038%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 9349008794
- Location
- Tempe, AZ · TIN 81-8461121
- Authorisation / referral
- PA2026164178 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $280.00 | $154.00 | — | — | DeniedCO27 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $1,801.00 | $990.55 | — | — | DeniedCO27 |
| Totals | $2,081.00 | $1,144.55 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-372366
- 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-023940 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-14 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 21 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026164178 on file for 43239. | |
| 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 Associates2026-03-14 09:22
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-04 00:43
Attachments
Documents received with the claim
- Prior auth letterPA2026164178_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-03-14 to 2026-06-12.
- Itemized billitemized_PA-372366.pdf2 pages
Itemised statement totalling $2081.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-14 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015892 | 2026-08-13 | Valley Internal Medicine Associates | $341.00 | Denied |
| CLM-2026-031806 | 2026-06-06 | Heritage Internal Medicine Associates | $369.00 | 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
Service after coverage termination.