CLM-2026-027331
Harbor Digestive Health Center, Gastroenterology. Service 2026-03-29 at outpatient hospital (POS 22). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Stephen Watkins
- Member ID
- UHC-21594-17
- Date of birth
- 1966-10-20
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-432654
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5660
- Coverage period
- 2025-08-01 to present
- Deductible
- $398.03 of $1,000.0040%
- Out-of-pocket maximum
- $137.87 of $2,000.007%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 9392708282
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- none / REF892405
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 | $215.00 | $118.25 | — | — | DeniedCO18 |
| Totals | $215.00 | $118.25 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-868814
- 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-016003 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-29: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 61 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-027330: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Center2026-03-29 13:31
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-05-29 04:20
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-868814.pdf8 pages
Itemised statement totalling $215.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-027330: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018365 | 2026-08-10 | Canyon Internal Medicine Associates | $177.00 | Approved |
| CLM-2026-022508 | 2026-04-21 | Summit Regional Medical Center | $5,120.00 | Approved |
| CLM-2026-027330 | 2026-03-29 | Harbor Digestive Health Center | $215.00 | 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
Exact duplicate of an earlier submission.