CLM-2026-024509
Evergreen GI Associates, Gastroenterology. Service 2026-02-19 at outpatient hospital (POS 22). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Mason Garcia
- Member ID
- UHC-90864-72
- Date of birth
- 2005-05-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416792
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-5928
- Coverage period
- 2022-01-01 to present
- Deductible
- $353.11 of $1,500.0024%
- Out-of-pocket maximum
- $36.38 of $3,000.001%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 8041133652
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- none / 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 | $335.00 | $184.25 | — | — | DeniedCO18 |
| Totals | $335.00 | $184.25 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- 2. K58.0 Irritable bowel syndrome with diarrhea
- Patient account
- PA-508304
- 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-022933 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-19: UNKNOWN (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-024508: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-02-19 17:46
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-17 00:23
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-508304.pdf9 pages
Itemised statement totalling $335.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-024508: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002588 | 2026-07-16 | Summit Reference Lab | $117.00 | Approved |
| CLM-2026-014778 | 2026-06-30 | Unity Counseling Center | $239.00 | Approved |
| CLM-2026-024508 | 2026-02-19 | Evergreen GI Associates | $335.00 | 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
Exact duplicate of an earlier submission.