CLM-2026-025050
Pinecrest GI Associates, Gastroenterology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-07-23.
Member
Resolved through the identity graph
- Member
- Brittany Kim
- Member ID
- UHC-44063-25
- Date of birth
- 1958-12-16
- Identity
- Verified6 records, confidence 1.00
- Claim record
- CLMCLM-403044
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2039
- Coverage period
- 2021-11-01 to 2026-03-26
- Deductible
- $2,584.86 of $3,500.0074%
- Out-of-pocket maximum
- $4,737.85 of $10,500.0045%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 2378227856
- Location
- Denver, CO · TIN 86-4406841
- 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 | $333.00 | $183.15 | — | — | DeniedCO27 |
| Totals | $333.00 | $183.15 | — | — | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-957029
- 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-023566 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-09 is after coverage terminated on 2026-03-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-07-09 13:53
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-23 03:40
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-23 10:08
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-957029.pdf3 pages
Itemised statement totalling $333.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-09 is after coverage terminated on 2026-03-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032372 | 2026-08-10 | Lakeside Physical Therapy | $258.00 | Denied |
| CLM-2026-020911 | 2026-07-22 | Evergreen Dermatology Clinic | $667.00 | Denied |
| CLM-2026-017050 | 2026-02-17 | Valley Primary Care Associates | $41.00 | Denied |
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
Service after coverage termination.