CLM-2026-013579
Pinecrest GI Associates, Gastroenterology. Service 2026-02-24 at outpatient hospital (POS 22). Received 2026-03-30.
Member
Resolved through the identity graph
- Member
- Brittany Bennett
- Member ID
- UHC-13990-39
- Date of birth
- 1976-03-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416176
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6717
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,223.27 of $3,500.0035%
- Out-of-pocket maximum
- $1,583.07 of $10,500.0015%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 3015676174
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2025097585 / 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 | $2,759.00 | $1,517.45 | $1,517.45 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1 | $2,058.00 | $1,131.90 | $796.54 | $335.36 | Paid |
| Totals | $4,817.00 | $2,649.35 | $2,313.99 | $335.36 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-964350
- 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-019564 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-24: MEDICARE-ADV-B (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 34 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025097585 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 Associates2026-02-24 18:52
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Prior auth letterPA2025097585_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-02-24 to 2026-05-25.
- Itemized billitemized_PA-964350.pdf9 pages
Itemised statement totalling $4817.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.