CLM-2026-025442
Evergreen GI Associates, Gastroenterology. Service 2026-08-06 at outpatient hospital (POS 22). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Charlotte Oliver
- Member ID
- UHC-71629-03
- Date of birth
- 1995-04-07
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-402096
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group NULL
- Coverage period
- 2022-04-01 to present
- Deductible
- $2,048.62 of $3,500.0059%
- Out-of-pocket maximum
- $4,926.24 of $10,500.0047%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 2930601507
- 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 | $230.00 | $126.50 | $126.50 | $0.00 | Paid |
| Totals | $230.00 | $126.50 | $126.50 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-864821
- 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-008131 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-08-06: - (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 30 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 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 Associates2026-08-06 12:58
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Itemized billitemized_PA-864821.pdf9 pages
Itemised statement totalling $230.00 across 1 line.
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
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.