CLM-2026-027223
Pinecrest GI Associates, Gastroenterology. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Gabriel Walker
- Member ID
- UHC-80576-44
- Date of birth
- 1976-02-08
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-401771
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4907
- Coverage period
- 2022-07-01 to present
- Deductible
- $435.46 of $1,000.0044%
- Out-of-pocket maximum
- $777.24 of $4,000.0019%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 5772273426
- Location
- Denver, CO · TIN 86-4406841
- 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 | $218.00 | $119.90 | — | — | DeniedCO197 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,666.00 | $1,466.30 | — | — | DeniedCO197 |
| Totals | $2,884.00 | $1,586.20 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- Patient account
- PA-646275
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040164 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-22: CORE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 45378 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Associates2026-07-22 09:17
Established patient presents with irritable bowel syndrome with diarrhea; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-31 06:20
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-31 12:07
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-646275.pdf5 pages
Itemised statement totalling $2884.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 45378 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.