CLM-2026-027971
Pinecrest GI Associates, Gastroenterology. Service 2026-08-08 at outpatient hospital (POS 22). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Justin Walker
- Member ID
- none on golden record
- Date of birth
- 1991-05-28
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412993
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 8203907240
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026059173 / 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 | $2,380.00 | $1,309.00 | — | — | PendedIDQ |
| 2 | 43239 rev 0750 | Upper GI endoscopy with biopsy | 25 | 1 | 1 | $1,316.00 | $723.80 | — | — | PendedIDQ |
| Totals | $3,696.00 | $2,032.80 | — | — | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-774406
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002386; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026059173 on file for 45378, 43239. | |
| 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 Associates2026-08-08 14:01
Patient seen for irritable bowel syndrome with diarrhea.
- SystemSystem: Claims system2026-08-30 04:32
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-08-30 12:51
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026059173_approval.pdf2 pages
Utilisation management approval letter for 45378 (Colonoscopy, diagnostic), valid 2026-08-08 to 2026-11-06.
- Itemized billitemized_PA-774406.pdf4 pages
Itemised statement totalling $3696.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002386; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.