CLM-2026-004279
Pinecrest GI Associates, Gastroenterology. Service 2026-03-18 at outpatient hospital (POS 22). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Wayne Lee
- Member ID
- UHC-57483-83
- Date of birth
- 1949-01-02
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-421807
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0957
- Coverage period
- 2025-04-01 to present
- Deductible
- $831.58 of $1,000.0083%
- Out-of-pocket maximum
- $445.62 of $4,000.0011%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 3324868967
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- none / REF214213
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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,179.00 | $1,198.45 | — | — | DeniedCO197 |
| Totals | $2,179.00 | $1,198.45 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-387242
- 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-007147 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-03-18: CORE-HMO (HMO), effective 2025-04-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 43239 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Pinecrest GI Associates (6204581436). | |
| 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 Associates2026-03-18 12:16
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-13 05:51
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-13 11:59
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-387242.pdf6 pages
Itemised statement totalling $2179.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 43239 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016404 | 2026-01-26 | Meadow Cardiovascular Associates | $652.00 | Approved |
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
Precertification required and absent.