CLM-2026-017143
Evergreen Digestive Health Center, Gastroenterology. Service 2026-09-02 at outpatient hospital (POS 22). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Joan Robertson
- Member ID
- none on golden record
- Date of birth
- 1957-11-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404249
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-0649
- Coverage period
- 2023-09-01 to present
- Deductible
- $653.87 of $1,000.0065%
- Out-of-pocket maximum
- $799.21 of $4,000.0020%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 7952112382
- 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 | $233.00 | $128.15 | — | — | PendedIDQ |
| Totals | $233.00 | $128.15 | — | — | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-297938
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002157; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-09-02: MEDICARE-ADV-B (MA), effective 2023-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 32 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 Center2026-09-02 14:28
Established patient presents with epigastric pain; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-297938.pdf7 pages
Itemised statement totalling $233.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002157; payment withheld until the identity is confirmed. Eligibility: Active on 2026-09-02: MEDICARE-ADV-B (MA), effective 2023-09-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.