CLM-2026-021572
Pinecrest GI Associates, Gastroenterology. Service 2026-04-22 at outpatient hospital (POS 22). Received 2026-06-01.
Member
Resolved through the identity graph
- Member
- Beverly Miller
- Member ID
- UHC-85811-35
- Date of birth
- 1938-01-27
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-402450
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5515
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,260.94 of $3,500.0036%
- Out-of-pocket maximum
- $3,515.87 of $14,000.0025%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 7038392792
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2026239937 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,616.00 | $1,438.80 | — | — | Review |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,442.00 | $793.10 | — | — | Review |
| Totals | $4,058.00 | $2,231.90 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-470856
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009144 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-22: CHOICE-PLUS-PPO (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026239937 on file for 70553, 43239. | |
| Provider network | Pass | In-network provider Pinecrest GI Associates (6204581436). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Associates2026-04-22 12:00
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-06-01 00:05
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026239937_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-22 to 2026-07-21.
- Itemized billitemized_PA-470856.pdf8 pages
Itemised statement totalling $4058.00 across 2 lines.
- Medical recordrecords_PA-470856.pdf6 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023491 | 2026-04-24 | Riverside Medical Group | $469.00 | Approved |
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
Notes document medical necessity.