CLM-2026-032159
Heritage GI Associates, Gastroenterology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-09-27.
Member
Resolved through the identity graph
- Member
- Terry Le
- Member ID
- UHC-38720-12
- Date of birth
- 1984-03-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427003
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4896
- Coverage period
- 2024-08-01 to present
- Deductible
- $713.74 of $1,500.0048%
- Out-of-pocket maximum
- $1,137.59 of $6,000.0019%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 8459983820
- Network
- In network
- Rendering NPI
- 9675766429
- Location
- Tempe, AZ · TIN 81-8461121
- Authorisation / referral
- none / REF590460
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 | $239.00 | $131.45 | — | — | Review |
| Totals | $239.00 | $131.45 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-539038
- 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-030615 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-05: NAVIGATE-HMO (HMO), effective 2024-08-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-032158, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Heritage GI Associates (8459983820). | |
| 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 Associates2026-09-05 17:54
Patient seen for gastro-esophageal reflux disease without esophagitis. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-09-27 02:31
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-09-27 12:06
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-539038.pdf7 pages
Itemised statement totalling $239.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-032158, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032158 | 2026-09-05 | Harbor Digestive Health Center | $239.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.