CLM-2026-006638
Pinecrest GI Associates, Gastroenterology. Service 2026-09-05 at outpatient hospital (POS 22). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Sara Murphy
- Member ID
- UHC-72812-48
- Date of birth
- 1953-07-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-429862
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4645
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,170.81 of $1,500.0078%
- Out-of-pocket maximum
- $1,016.74 of $6,000.0017%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 7759550461
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2026155837 / 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 | $1,434.00 | $788.70 | — | — | Review |
| Totals | $1,434.00 | $788.70 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-699407
- 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-018396 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-05: SELECT-EPO (EPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026155837 on file for 45378. | |
| 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 | Review | CO16 | Documentation incomplete: “Patient seen for gastro-esophageal reflux disease without esophagitis. Note dictated; sign”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest GI Associates2026-09-05 16:47
Patient seen for gastro-esophageal reflux disease without esophagitis. Note dictated; signature pending.
- SystemSystem: Claims system2026-10-05 03:47
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2026155837_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-05 to 2026-12-04.
- Itemized billitemized_PA-699407.pdf5 pages
Itemised statement totalling $1434.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for gastro-esophageal reflux disease without esophagitis. Note dictated; sign”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002973 | 2026-02-05 | Heritage Family Practice | $223.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.