CLM-2026-000823
Pinecrest GI Associates, Gastroenterology. Service 2026-03-25 at outpatient hospital (POS 22). Received 2026-04-19.
Member
Resolved through the identity graph
- Member
- Joseph Scott
- Member ID
- UHC-72343-79
- Date of birth
- 1975-08-21
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408137
- Relationship
- Child, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-1972
- Coverage period
- 2021-05-01 to present
- Deductible
- $61.03 of $3,500.002%
- Out-of-pocket maximum
- $4,879.04 of $14,000.0035%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 6123051370
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2025658186 / 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 | $2,137.00 | $1,175.35 | $1,175.35 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,307.00 | $718.85 | $718.85 | $0.00 | Paid |
| Totals | $3,444.00 | $1,894.20 | $1,894.20 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-547713
- 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-021986 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-25: NULL (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025658186 on file for 45378, 43239. | |
| Provider network | Pass | In-network provider Pinecrest GI Associates (3588910497). | |
| 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: Pinecrest GI Associates2026-03-25 15:52
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2025658186_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-03-25 to 2026-06-23.
- Itemized billitemized_PA-547713.pdf9 pages
Itemised statement totalling $3444.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015082 | 2026-07-24 | Lakeside Medical Group | $1,977.00 | Needs review |
| CLM-2026-003116 | 2026-04-01 | Summit Digestive Health Center | $3,561.00 | Needs review |
| CLM-2026-026014 | 2026-03-01 | Mesa Physical Therapy | $519.00 | Approved |
| CLM-2026-034160 | 2026-02-20 | Lakeside Bone and Joint Center | $10,730.00 | 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.