CLM-2026-023664
Pinecrest GI Associates, Gastroenterology. Service 2026-02-17 at outpatient hospital (POS 22). Received 2026-08-03.
Member
Resolved through the identity graph
- Member
- Sofia Wilson
- Member ID
- UHC-06608-41
- Date of birth
- 2004-06-18
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415342
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2717
- Coverage period
- 2024-01-01 to present
- Deductible
- $874.49 of $2,500.0035%
- Out-of-pocket maximum
- $1,002.09 of $10,000.0010%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 2516632157
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2026728253 / 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 | $210.00 | $115.50 | — | — | DeniedCO29 |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1,2 | $2,375.00 | $1,306.25 | — | — | DeniedCO29 |
| Totals | $2,585.00 | $1,421.75 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-340063
- 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-034141 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-17: N/A (PPO), effective 2024-01-01. | |
| Timely filing | Fail | CO29 | Received 167 days after the last date of service (limit 90). Time limit for filing has expired |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026728253 on file for 43239. | |
| Provider network | Pass | In-network provider Pinecrest GI Associates (6204581436). | |
| 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 Associates2026-02-17 12:51
Patient seen for encounter for screening for malignant neoplasm of colon.
- SystemSystem: Claims system2026-08-03 06:21
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Prior auth letterPA2026728253_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-02-17 to 2026-05-18.
- Itemized billitemized_PA-340063.pdf7 pages
Itemised statement totalling $2585.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 167 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007521 | 2026-10-10 | Sunrise Behavioral Health | $263.00 | Approved |
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
Received after the timely-filing limit.