CLM-2026-002664
Evergreen GI Associates, Gastroenterology. Service 2026-09-02 at outpatient hospital (POS 22). Received 2026-09-24.
Member
Resolved through the identity graph
- Member
- Diana Ryan
- Member ID
- UHC-42761-74
- Date of birth
- 1945-09-14
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407645
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1041
- Coverage period
- 2021-11-01 to 2026-02-22
- Deductible
- $25.98 of $2,500.001%
- Out-of-pocket maximum
- $1,286.65 of $10,000.0013%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 2420113146
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- none / REF167571
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 | $270.00 | $148.50 | — | — | DeniedCO27 |
| Totals | $270.00 | $148.50 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-995983
- 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-029922 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-02 is after coverage terminated on 2026-02-22. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 Evergreen GI Associates (1347472536). | |
| 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: Evergreen GI Associates2026-09-02 14:35
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-24 00:35
Attachments
Documents received with the claim
- Itemized billitemized_PA-995983.pdf2 pages
Itemised statement totalling $270.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-02 is after coverage terminated on 2026-02-22.
Other claims for this member
Same resolved identity
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
Service after coverage termination.