CLM-2026-021830
Pinecrest GI Associates, Gastroenterology. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Madison Taylor
- Member ID
- UHC-49436-32
- Date of birth
- 1957-06-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-417007
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2720
- Coverage period
- 2021-02-01 to present
- Deductible
- $854.26 of $1,500.0057%
- Out-of-pocket maximum
- $2,010.68 of $4,500.0045%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 7912601599
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026715874 / 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 | $196.00 | $107.80 | $107.80 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1 | $2,321.00 | $1,276.55 | $611.80 | $664.75 | Paid |
| Totals | $2,517.00 | $1,384.35 | $719.60 | $664.75 | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-689976
- 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-027985 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: MEDICARE-ADV-B (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026715874 on file for 43239. | |
| 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 Associates2026-03-27 18:43
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026715874_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-03-27 to 2026-06-25.
- Itemized billitemized_PA-689976.pdf4 pages
Itemised statement totalling $2517.00 across 2 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-2026-026262 | 2026-06-23 | Meadow Physical Therapy | $407.00 | 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.