CLM-2026-025687
Harbor Digestive Health Center, Gastroenterology. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Samantha Clark
- Member ID
- UHC-89552-08
- Date of birth
- 1944-06-24
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-415369
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-0716
- Coverage period
- 2021-04-01 to present
- Deductible
- $2,286.25 of $3,500.0065%
- Out-of-pocket maximum
- $429.55 of $10,500.004%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 8033187724
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $286.00 | $157.30 | $157.30 | $0.00 | Paid |
| Totals | $286.00 | $157.30 | $157.30 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-342889
- 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-011051 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-21: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Center2026-07-21 10:24
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-08-29 00:33
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-29 11:02
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-342889.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-342889.pdf5 pages
Itemised statement totalling $286.00 across 1 line.
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
Authorisation must be confirmed with UM before payment.