CLM-2026-018204
Evergreen GI Associates, Gastroenterology. Service 2026-04-21 at outpatient hospital (POS 22). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Shirley Lee
- Member ID
- UHC-25265-26
- Date of birth
- 2007-05-12
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-421758
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5829
- Coverage period
- 2024-03-01 to present
- Deductible
- $63.79 of $500.0013%
- Out-of-pocket maximum
- $582.02 of $2,000.0029%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 1233776784
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- PA2026686313 / REF829592
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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,563.00 | $859.65 | $563.24 | $296.41 | Paid |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1 | $351.00 | $193.05 | $57.92 | $135.13 | Paid |
| 3 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,402.00 | $771.10 | $231.33 | $539.77 | Paid |
| Totals | $3,316.00 | $1,823.80 | $852.49 | $971.31 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-469278
- 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-003043 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-21: CORE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026686313 on file for 43239, 45378. | |
| Provider network | Pass | In-network provider Evergreen GI Associates (1347472536). | |
| 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 GI Associates2026-04-21 13:19
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026686313_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-04-21 to 2026-07-20.
- Itemized billitemized_PA-469278.pdf7 pages
Itemised statement totalling $3316.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031976 | 2026-01-04 | Pinecrest Reference Lab | $30.00 | Needs review |
| CLM-2026-031975 | 2026-01-04 | Pinecrest Reference Lab | $30.00 | 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.