CLM-2026-026381
Heritage GI Associates, Gastroenterology. Service 2026-08-22 at outpatient hospital (POS 22). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Joseph Vargas
- Member ID
- UHC-78519-23
- Date of birth
- 1967-03-08
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-418421
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0797
- Coverage period
- 2025-07-01 to present
- Deductible
- $264.43 of $500.0053%
- Out-of-pocket maximum
- $391.68 of $2,000.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 1763460205
- Location
- Phoenix, AZ · TIN 80-4628895
- 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,488.00 | $1,368.40 | — | — | DeniedCO197 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 2 | $347.00 | $190.85 | — | — | DeniedCO197 |
| Totals | $2,835.00 | $1,559.25 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-769389
- 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-036682 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-22: MEDICARE-ADV-A (MA), effective 2025-07-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Associates2026-08-22 09:14
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-19 04:12
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-769389.pdf7 pages
Itemised statement totalling $2835.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010806 | 2026-08-10 | Heritage Family Practice | $445.00 | Approved |
| CLM-2026-000761 | 2026-06-21 | Mesa Medical Group | $357.00 | 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
Precertification required and absent.