CLM-2026-030362
Heritage GI Associates, Gastroenterology. Service 2025-12-09 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Joey Ward
- Member ID
- UHC-28293-97
- Date of birth
- 1957-04-24
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-412453
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group NULL
- Coverage period
- 2025-03-01 to present
- Deductible
- $1,635.30 of $2,500.0065%
- Out-of-pocket maximum
- $1,909.07 of $5,000.0038%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 4356479665
- 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,026.00 | $1,114.30 | — | — | DeniedCO197 |
| Totals | $2,026.00 | $1,114.30 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-695873
- 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-002436 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-09: MEDICARE-ADV-A (MA), effective 2025-03-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 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 Associates2025-12-09 11:51
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-08 05:10
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-695873.pdf4 pages
Itemised statement totalling $2026.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009284 | 2026-01-03 | Unity Medical Group | $356.00 | Denied |
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.