CLM-2026-031803
Heritage Digestive Health Center, Gastroenterology. Service 2026-01-30 at office (POS 11). Received 2026-03-22.
Member
Resolved through the identity graph
- Member
- Thomas Chapman
- Member ID
- UHC-12402-61
- Date of birth
- 1967-01-23
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-416920
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5862
- Coverage period
- 2024-11-01 to present
- Deductible
- $1,380.46 of $2,500.0055%
- Out-of-pocket maximum
- $1,195.96 of $5,000.0024%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 4437349366
- Network
- In network
- Rendering NPI
- 4546088392
- Location
- San Diego, CA · TIN 67-1701611
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $269.00 | $166.78 | — | — | DeniedCO18 |
| Totals | $269.00 | $166.78 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-309726
- 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-008014 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-30: NULL (PPO), effective 2024-11-01. | |
| Timely filing | Pass | Received 51 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-031802: 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 Heritage Digestive Health Center (4437349366). | |
| 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 Digestive Health Center2026-01-30 11:26
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-03-22 00:52
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-22 08:34
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-031802: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020857 | 2026-05-18 | Evergreen Orthopedic Specialists | $50,331.00 | Needs review |
| CLM-2026-031802 | 2026-01-30 | Heritage Digestive Health Center | $269.00 | 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.