CLM-2026-004405
Pinecrest GI Associates, Gastroenterology. Service 2026-05-25 at outpatient hospital (POS 22). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Rebecca Jones
- Member ID
- UHC-46908-53
- Date of birth
- 1967-05-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431471
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0894
- Coverage period
- 2024-05-01 to present
- Deductible
- $851.45 of $2,500.0034%
- Out-of-pocket maximum
- $763.12 of $10,000.008%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 4043775863
- Location
- Denver, CO · TIN 86-4406841
- 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 | $196.00 | $107.80 | — | — | DeniedCO18 |
| Totals | $196.00 | $107.80 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-773804
- 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-011536 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-25: CORE-HMO (HMO), effective 2024-05-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-004404: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-05-25 14:47
Patient seen for gastro-esophageal reflux disease without esophagitis.
- SystemSystem: Claims system2026-07-04 05:21
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-773804.pdf3 pages
Itemised statement totalling $196.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-004404: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004404 | 2026-05-25 | Pinecrest GI Associates | $196.00 | 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
Exact duplicate of an earlier submission.