CLM-2026-009353
Pinecrest GI Associates, Gastroenterology. Service 2026-01-03 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Logan Hamilton
- Member ID
- UHC-20469-91
- Date of birth
- 1972-01-12
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-409235
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8065
- Coverage period
- 2024-06-01 to present
- Deductible
- $282.61 of $1,000.0028%
- Out-of-pocket maximum
- $885.51 of $2,000.0044%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 3563820752
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2026185358 / REF365329
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 | $277.00 | $152.35 | $152.35 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 2 | $1,448.00 | $796.40 | $634.45 | $161.95 | Paid |
| Totals | $1,725.00 | $948.75 | $786.80 | $161.95 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-818966
- 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-006408 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-01-03: CORE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 18 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026185358 on file for 43239. | |
| 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 | 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 Associates2026-01-03 14:02
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026185358_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-03 to 2026-04-03.
- Itemized billitemized_PA-818966.pdf2 pages
Itemised statement totalling $1725.00 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-2026-027919 | 2026-05-14 | Riverside Medical Group | $22.00 | Approved |
| CLM-2026-016949 | 2026-01-29 | Lakeside Physical Therapy | $281.00 | Denied |
| CLM-2026-016948 | 2026-01-29 | Lakeside Physical Therapy | $281.00 | 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.