CLM-2026-026593
Evergreen GI Associates, Gastroenterology. Service 2026-06-03 at outpatient hospital (POS 22). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Susan Wagner
- Member ID
- UHC-34302-68
- Date of birth
- 2007-07-17
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-405154
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6737
- Coverage period
- 2021-02-01 to present
- Deductible
- $382.47 of $500.0076%
- Out-of-pocket maximum
- $20.22 of $1,500.001%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 6130278834
- 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 | $282.00 | $155.10 | $128.80 | $26.30 | Paid |
| Totals | $282.00 | $155.10 | $128.80 | $26.30 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-964013
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038358 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-03: CHOICE-PLUS-PPO (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 41 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 Associates2026-06-03 10:14
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Itemized billitemized_PA-964013.pdf8 pages
Itemised statement totalling $282.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean 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.