CLM-2026-027134
Pinecrest GI Associates, Gastroenterology. Service 2026-01-22 at outpatient hospital (POS 22). Received 2026-02-15.
Member
Resolved through the identity graph
- Member
- Sharon Davis
- Member ID
- UHC-66321-60
- Date of birth
- 1989-10-12
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-415877
- Relationship
- Child, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4947
- Coverage period
- 2022-08-01 to present
- Deductible
- $1,450.70 of $3,500.0041%
- Out-of-pocket maximum
- $575.21 of $7,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 6204581436
- Network
- In network
- Rendering NPI
- 2492981297
- Location
- Scottsdale, AZ · TIN 29-4594726
- Authorisation / referral
- PA2025579300 / 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 | $258.00 | $141.90 | $141.90 | $0.00 | Paid |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,810.00 | $995.50 | $995.50 | $0.00 | Paid |
| Totals | $2,068.00 | $1,137.40 | $1,137.40 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-977182
- 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-013373 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-22: SELECT-EPO (EPO), effective 2022-08-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025579300 on file for 43239. | |
| 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 Associates2026-01-22 09:04
Established patient presents with encounter for screening for malignant neoplasm of colon; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025579300_approval.pdf2 pages
Utilisation management approval letter for 88305 (Surgical pathology, level IV), valid 2026-01-22 to 2026-04-22.
- Itemized billitemized_PA-977182.pdf2 pages
Itemised statement totalling $2068.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022804 | 2026-02-13 | Mesa Medical Group | $236.00 | Approved |
| CLM-2026-025959 | 2026-02-10 | Evergreen Primary Care Associates | $3,187.00 | Needs review |
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.