CLM-2026-026033
Harbor Digestive Health Center, Gastroenterology. Service 2026-05-01 at outpatient hospital (POS 22). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Camila Hart
- Member ID
- UHC-37443-96
- Date of birth
- 1953-08-18
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-420635
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0938
- Coverage period
- 2022-06-01 to present
- Deductible
- $921.41 of $2,500.0037%
- Out-of-pocket maximum
- $53.40 of $5,000.001%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 5938201295
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- none / REF169953
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 | $198.00 | $108.90 | — | — | Review |
| Totals | $198.00 | $108.90 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-352215
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010163 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-01: NAVIGATE-HMO (HMO), effective 2022-06-01. | |
| Timely filing | Pass | Received 16 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 | Review | CO16 | Documentation incomplete: “Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewe”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Digestive Health Center2026-05-01 10:53
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-05-17 06:19
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-352215.pdf7 pages
Itemised statement totalling $198.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewe”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011392 | 2026-04-01 | Lakeside Internal Medicine Associates | $638.00 | Approved |
| CLM-2026-021421 | 2026-01-06 | Mesa Family Practice | $259.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.