CLM-2026-016760
Pinecrest GI Associates, Gastroenterology. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-05-07.
Member
Resolved through the identity graph
- Member
- Samuel Williamson
- Member ID
- UHC-27141-39
- Date of birth
- 2003-01-11
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-406923
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8474
- Coverage period
- 2023-10-01 to present
- Deductible
- $156.54 of $500.0031%
- Out-of-pocket maximum
- $292.73 of $1,500.0020%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 4140693415
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2025400172 / 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 | $197.00 | $108.35 | $108.35 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,815.00 | $998.25 | $387.74 | $610.51 | Paid |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,896.00 | $1,042.80 | $208.56 | $834.24 | Paid |
| Totals | $3,908.00 | $2,149.40 | $704.65 | $1,444.75 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-318731
- 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-029362 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-05-03: N/A (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025400172 on file for 43239, 45378. | |
| 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 Associates2026-05-03 10:30
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025400172_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-318731.pdf8 pages
Itemised statement totalling $3908.00 across 3 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.