CLM-2026-026688
Pinecrest GI Associates, Gastroenterology. Service 2026-04-01 at outpatient hospital (POS 22). Received 2026-04-05.
Member
Resolved through the identity graph
- Member
- Nancy Richards
- Member ID
- UHC-93715-49
- Date of birth
- 1948-06-12
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-426643
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6136
- Coverage period
- 2021-01-01 to 2026-04-01
- Deductible
- $827.74 of $1,000.0083%
- Out-of-pocket maximum
- $322.10 of $4,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 3499055119
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2026506847 / 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 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,579.00 | $1,418.45 | $421.50 | $996.95 | Paid |
| Totals | $2,579.00 | $1,418.45 | $421.50 | $996.95 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-246049
- 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-011033 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-01: - (PPO), effective 2021-01-01, terms 2026-04-01. | |
| Timely filing | Pass | Received 4 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026506847 on file for 45378. | |
| Provider network | Pass | In-network provider Pinecrest GI Associates (6204581436). | |
| 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 Associates2026-04-01 10:52
Follow-up for epigastric pain. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-05 05:57
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-04-05 13:42
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026506847_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-04-01 to 2026-06-30.
- Itemized billitemized_PA-246049.pdf7 pages
Itemised statement totalling $2579.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021503 | 2026-03-08 | Summit Internal Medicine Associates | $367.00 | 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
Service after coverage termination.