CLM-2026-026678
Pinecrest GI Associates, Gastroenterology. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-01.
Member
Resolved through the identity graph
- Member
- Camila Olson
- Member ID
- UHC-51240-43
- Date of birth
- 1938-06-17
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-403487
- Relationship
- Spouse, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4215
- Coverage period
- 2024-04-01 to present
- Deductible
- $379.13 of $3,500.0011%
- Out-of-pocket maximum
- $3,540.46 of $14,000.0025%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 3446409633
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026854474 / 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 | $245.00 | $134.75 | $134.75 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,820.00 | $1,001.00 | $1,001.00 | $0.00 | Paid |
| Totals | $2,065.00 | $1,135.75 | $1,135.75 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-235514
- 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-006706 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-07-21: NULL (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026854474 on file for 45378. | |
| 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 Associates2026-07-21 11:52
Patient seen for encounter for screening for malignant neoplasm of colon.
Attachments
Documents received with the claim
- Prior auth letterPA2026854474_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-07-21 to 2026-10-19.
- Itemized billitemized_PA-235514.pdf4 pages
Itemised statement totalling $2065.00 across 2 lines.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011624 | 2026-08-26 | Heritage Medical Group | $302.00 | Approved |
| CLM-2026-021906 | 2026-01-24 | Valley Imaging Center | $2,510.00 | Approved |
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.