CLM-2026-032874
Heritage GI Associates, Gastroenterology. Service 2026-03-12 at outpatient hospital (POS 22). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Walter Ortega
- Member ID
- UHC-32319-15
- Date of birth
- 1960-11-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402056
- Relationship
- Child, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-8463
- Coverage period
- 2023-09-01 to present
- Deductible
- $1,100.62 of $3,500.0031%
- Out-of-pocket maximum
- $3,665.40 of $10,500.0035%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1403256369
- Network
- In network
- Rendering NPI
- 4156721217
- 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 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $344.00 | $189.20 | $189.20 | $0.00 | Paid |
| Totals | $344.00 | $189.20 | $189.20 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-208958
- 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-009929 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-12: NULL (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 33 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-03-12 17:12
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-208958.pdf9 pages
Itemised statement totalling $344.00 across 1 line.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003680 | 2026-01-23 | Mesa Physical Therapy | $519.00 | Approved |
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.