CLM-2026-028888
Evergreen Digestive Health Center, Gastroenterology. Service 2026-08-26 at outpatient hospital (POS 22). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Kimberly Simmons
- Member ID
- UHC-05418-33
- Date of birth
- 1997-02-12
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-419469
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2967
- Coverage period
- 2024-10-01 to present
- Deductible
- $455.02 of $1,500.0030%
- Out-of-pocket maximum
- $1,986.21 of $6,000.0033%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 5151368227
- Location
- San Diego, CA · TIN 71-8732123
- Authorisation / referral
- PA2026082154 / 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 | 43239 rev 0750 | Upper GI endoscopy with biopsy | — | 1 | 1 | $1,810.00 | $995.50 | $995.50 | $0.00 | Paid |
| Totals | $1,810.00 | $995.50 | $995.50 | $0.00 | ||||||
- 1. Z12.11 Encounter for screening for malignant neoplasm of colonprincipal
- Patient account
- PA-478979
- 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-004525 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-26: OPTIONS-PPO (PPO), effective 2024-10-01. | |
| 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 PA2026082154 on file for 43239. | |
| Provider network | Pass | In-network provider Evergreen Digestive Health Center (7438481310). | |
| 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: Evergreen Digestive Health Center2026-08-26 10:39
Follow-up for encounter for screening for malignant neoplasm of colon. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026082154_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-26 to 2026-11-24.
- Itemized billitemized_PA-478979.pdf7 pages
Itemised statement totalling $1810.00 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-2026-004552 | 2026-07-06 | Meadow Primary Care Associates | $177.00 | 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.