CLM-2026-026844
Harbor Digestive Health Center, Gastroenterology. Service 2025-12-10 at outpatient hospital (POS 22). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Jordan Kelley
- Member ID
- none on golden record
- Date of birth
- 1953-06-05
- Identity
- Verified3 records, confidence 0.93
- Claim record
- CLMCLM-430491
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by name and date of birth
- Plan
- NAVIGATE-HMO HMO group GRP-5847
- Coverage period
- 2021-04-01 to present
- Deductible
- $505.29 of $1,000.0051%
- Out-of-pocket maximum
- $834.26 of $2,000.0042%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- 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
- 7819622912
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2025277840 / REF351876
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 | $1,389.00 | $763.95 | $521.63 | $242.32 | Paid |
| Totals | $1,389.00 | $763.95 | $521.63 | $242.32 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-894679
- 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-005351 (verified, link confidence 0.93). | |
| Eligibility | Note | Active on 2025-12-10: NAVIGATE-HMO (HMO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025277840 on file for 43239. | |
| 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 Center2025-12-10 12:45
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025277840_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2025-12-10 to 2026-03-10.
- Itemized billitemized_PA-894679.pdf4 pages
Itemised statement totalling $1389.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Eligibility: Active on 2025-12-10: NAVIGATE-HMO (HMO), effective 2021-04-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032757 | 2026-05-15 | Northgate Internal Medicine Associates | $66.00 | Approved |
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
Clean claim, priced at contract rate.