CLM-2026-006859
Evergreen GI Associates, Gastroenterology. Service 2026-09-23 at outpatient hospital (POS 22). Received 2026-10-16.
Member
Resolved through the identity graph
- Member
- Sara Wallace
- Member ID
- UHC-78913-28
- Date of birth
- 1992-04-20
- Identity
- Verified4 records, confidence 0.98
- Claim record
- CLMCLM-423933
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5227
- Coverage period
- 2022-10-01 to present
- Deductible
- $1,814.92 of $3,500.0052%
- Out-of-pocket maximum
- $1,774.20 of $14,000.0013%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 2466251453
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- PA2025429793 / 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 | $1,820.00 | $1,001.00 | $1,001.00 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,156.00 | $1,185.80 | $784.42 | $401.38 | Paid |
| Totals | $3,976.00 | $2,186.80 | $1,785.42 | $401.38 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-884104
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014779 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-09-23: CHOICE-PLUS-PPO (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025429793 on file for 45378, 43239. | |
| 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 Associates2026-09-23 15:25
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 letterPA2025429793_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-09-23 to 2026-12-22.
- Itemized billitemized_PA-884104.pdf3 pages
Itemised statement totalling $3976.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006860 | 2026-09-23 | Summit Digestive Health Center | $3,976.00 | Needs review |
| CLM-2026-021189 | 2026-02-13 | Riverside Medical Group | $256.00 | Needs review |
| CLM-2026-021188 | 2026-02-13 | Riverside Medical Group | $256.00 | Approved |
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.