CLM-2026-007808
Pinecrest GI Associates, Gastroenterology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-02-08.
Member
Resolved through the identity graph
- Member
- Sophia Lynch
- Member ID
- UHC-01980-86
- Date of birth
- 1967-10-21
- Identity
- Verified7 records, confidence 0.97
- Claim record
- CLMCLM-406260
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-9630
- Coverage period
- 2023-08-01 to present
- Deductible
- $723.32 of $2,500.0029%
- Out-of-pocket maximum
- $610.20 of $7,500.008%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 5860166417
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026499605 / 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 | $1,513.00 | $832.15 | $832.15 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $2,364.00 | $1,300.20 | $980.10 | $320.10 | Paid |
| Totals | $3,877.00 | $2,132.35 | $1,812.25 | $320.10 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-384378
- 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-008897 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-31: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026499605 on file for 45378, 43239. | |
| 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 Associates2025-12-31 10:14
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026499605_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2025-12-31 to 2026-03-31.
- Itemized billitemized_PA-384378.pdf9 pages
Itemised statement totalling $3877.00 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-2026-027668 | 2026-07-06 | Sunrise Community Hospital | $1,431.00 | Approved |
| CLM-2026-019292 | 2026-06-18 | Unity Primary Care Associates | $2,911.00 | Needs review |
| CLM-2026-007809 | 2025-12-31 | Pinecrest GI Associates | $3,877.00 | Denied |
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.