CLM-2026-029540
Heritage GI Associates, Gastroenterology. Service 2026-10-10 at outpatient hospital (POS 22). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Mary Munz
- Member ID
- UHC-13183-92
- Date of birth
- 1956-02-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431465
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4303
- Coverage period
- 2022-12-01 to 2026-06-24
- Deductible
- $1,731.10 of $2,500.0069%
- Out-of-pocket maximum
- $759.46 of $5,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 4904647318
- Location
- Phoenix, AZ · TIN 80-4628895
- Authorisation / referral
- PA2026111526 / 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 | $2,107.00 | $1,158.85 | — | — | DeniedCO27 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 2 | $2,240.00 | $1,232.00 | — | — | DeniedCO27 |
| Totals | $4,347.00 | $2,390.85 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-701119
- 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-006356 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-10-10 is after coverage terminated on 2026-06-24. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026111526 on file for 43239, 45378. | |
| 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 Associates2026-10-10 12:16
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-14 04:48
Attachments
Documents received with the claim
- Prior auth letterPA2026111526_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-10-10 to 2027-01-08.
- Itemized billitemized_PA-701119.pdf4 pages
Itemised statement totalling $4347.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-10-10 is after coverage terminated on 2026-06-24.
Other claims for this member
Same resolved identity
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
Service after coverage termination.