CLM-2026-021363
Evergreen GI Associates, Gastroenterology. Service 2026-07-28 at outpatient hospital (POS 22). Received 2026-08-22.
Member
Resolved through the identity graph
- Member
- Gerald Bennett
- Member ID
- UHC-84632-41
- Date of birth
- 1978-08-07
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-410870
- Relationship
- Self, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7931
- Coverage period
- 2022-08-01 to present
- Deductible
- $406.56 of $3,500.0012%
- Out-of-pocket maximum
- $2,570.26 of $7,000.0037%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 7056011985
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- PA2025066609 / REF835688
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 | $2,063.00 | $1,134.65 | $1,134.65 | $0.00 | Paid |
| Totals | $2,063.00 | $1,134.65 | $1,134.65 | $0.00 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-984511
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-041848 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-28: NAVIGATE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025066609 on file for 43239. | |
| 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 Associates2026-07-28 17:42
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025066609_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-07-28 to 2026-10-26.
- Itemized billitemized_PA-984511.pdf6 pages
Itemised statement totalling $2063.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004639 | 2026-08-12 | Heritage Medical Group | $506.00 | Denied |
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.