CLM-2026-018217
Pinecrest GI Associates, Gastroenterology. Service 2026-01-15 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Judith Jacobs
- Member ID
- UHC-48697-92
- Date of birth
- 1941-10-18
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-406306
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5550
- Coverage period
- 2023-04-01 to 2026-02-03
- Deductible
- $14.16 of $1,000.001%
- Out-of-pocket maximum
- $810.38 of $3,000.0027%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 6618964988
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026734449 / REF752002
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 | $1,434.00 | $788.70 | $788.70 | $0.00 | Paid |
| Totals | $1,434.00 | $788.70 | $788.70 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-196657
- 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-006479 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-15: CORE-HMO (HMO), effective 2023-04-01, terms 2026-02-03. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026734449 on file for 45378. | |
| 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 Associates2026-01-15 12:48
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026734449_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-01-15 to 2026-04-15.
- Itemized billitemized_PA-196657.pdf6 pages
Itemised statement totalling $1434.00 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-2026-021845 | 2026-03-22 | Lakeside Clinical Laboratories | $142.00 | Denied |
| CLM-2026-033711 | 2025-12-18 | Summit Counseling Center | $253.00 | 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.