CLM-2026-010248
Evergreen Digestive Health Center, Gastroenterology. Service 2025-12-31 at outpatient hospital (POS 22). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Carolyn Sanchez
- Member ID
- UHC-29227-75
- Date of birth
- 2006-03-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417081
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6162
- Coverage period
- 2023-12-01 to present
- Deductible
- $931.74 of $1,500.0062%
- Out-of-pocket maximum
- $1,997.67 of $6,000.0033%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 1806450114
- Location
- San Diego, CA · TIN 71-8732123
- 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 | $318.00 | $174.90 | $174.90 | $0.00 | Paid |
| Totals | $318.00 | $174.90 | $174.90 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-139056
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007385 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-31: SELECT-EPO (EPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen Digestive Health Center (7438481310). | |
| 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 Digestive Health Center2025-12-31 16:57
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-139056.pdf8 pages
Itemised statement totalling $318.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031626 | 2025-12-14 | Desert Primary Care Associates | $211.00 | Needs review |
| CLM-2026-031625 | 2025-12-14 | Riverside Family Practice | $211.00 | 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.