CLM-2026-004324
Pinecrest GI Associates, Gastroenterology. Service 2026-03-15 at outpatient hospital (POS 22). Received 2026-04-18.
Member
Resolved through the identity graph
- Member
- Charlotte Meyer
- Member ID
- UHC-88643-22
- Date of birth
- 1965-07-01
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425439
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8997
- Coverage period
- 2024-04-01 to present
- Deductible
- $443.52 of $500.0089%
- Out-of-pocket maximum
- $604.41 of $1,500.0040%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 5976616495
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026141140 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,362.00 | $1,299.10 | $429.27 | $869.83 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,420.00 | $781.00 | $234.30 | $546.70 | Paid |
| Totals | $3,782.00 | $2,080.10 | $663.57 | $1,416.53 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-706708
- 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-013937 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-15: SELECT-EPO (EPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026141140 on file for 43239, 45378. | |
| 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 Associates2026-03-15 12:43
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026141140_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-03-15 to 2026-06-13.
- Itemized billitemized_PA-706708.pdf8 pages
Itemised statement totalling $3782.00 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
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.