CLM-2026-032152
Harbor Digestive Health Center, Gastroenterology. Service 2026-09-18 at outpatient hospital (POS 22). Received 2026-10-14.
Member
Resolved through the identity graph
- Member
- Jason Alexander
- Member ID
- UHC-25888-14
- Date of birth
- 1980-11-03
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-400120
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8108
- Coverage period
- 2022-02-01 to present
- Deductible
- $735.62 of $1,000.0074%
- Out-of-pocket maximum
- $546.40 of $4,000.0014%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7922422671
- Network
- In network
- Rendering NPI
- 7605290445
- Location
- Tempe, AZ · TIN 89-3478747
- Authorisation / referral
- PA2026486059 / 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $296.00 | $162.80 | $162.80 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,511.00 | $831.05 | $174.53 | $656.52 | Paid |
| Totals | $1,807.00 | $993.85 | $337.33 | $656.52 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-334655
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040449 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-18: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026486059 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 Center2026-09-18 18:54
Established patient presents with gastro-esophageal reflux disease without esophagitis; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026486059_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-09-18 to 2026-12-17.
- Itemized billitemized_PA-334655.pdf6 pages
Itemised statement totalling $1807.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.