CLM-2026-018840
Evergreen Digestive Health Center, Gastroenterology. Service 2026-07-02 at outpatient hospital (POS 22). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Camila Smith
- Member ID
- UHC-76027-62
- Date of birth
- 1979-08-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-408124
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1268
- Coverage period
- 2022-12-01 to 2026-05-25
- Deductible
- $2,053.77 of $2,500.0082%
- Out-of-pocket maximum
- $119.37 of $5,000.002%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 8131351537
- Location
- San Diego, CA · TIN 71-8732123
- Authorisation / referral
- PA2025572870 / 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 | $183.00 | $100.65 | — | — | DeniedCO27 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,528.00 | $840.40 | — | — | DeniedCO27 |
| Totals | $1,711.00 | $941.05 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-769519
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-037957 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-02 is after coverage terminated on 2026-05-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025572870 on file for 43239. | |
| 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 Center2026-07-02 13:44
Follow-up for irritable bowel syndrome with diarrhea. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-10 06:55
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-10 15:15
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025572870_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-02 to 2026-09-30.
- Itemized billitemized_PA-769519.pdf4 pages
Itemised statement totalling $1711.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-02 is after coverage terminated on 2026-05-25.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.