CLM-2026-030112
Pinecrest GI Associates, Gastroenterology. Service 2026-06-23 at outpatient hospital (POS 22). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Andrea Stone
- Member ID
- UHC-78915-54
- Date of birth
- 1993-07-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406399
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8365
- Coverage period
- 2021-10-01 to present
- Deductible
- $819.71 of $1,000.0082%
- Out-of-pocket maximum
- $573.30 of $2,000.0029%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 9691578360
- 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 | $251.00 | $138.05 | — | — | DeniedCO197 |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,660.00 | $1,463.00 | — | — | DeniedCO197 |
| Totals | $2,911.00 | $1,601.05 | — | — | ||||||
- 1. K21.9 Gastro-esophageal reflux disease without esophagitisprincipal
- Patient account
- PA-920797
- 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-000479 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: MEDICARE-ADV-B (MA), effective 2021-10-01. | |
| Timely filing | Pass | Received 20 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 Associates2026-06-23 18:38
Follow-up for gastro-esophageal reflux disease without esophagitis. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-13 01:25
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-13 17:24
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-920797.pdf6 pages
Itemised statement totalling $2911.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034623 | 2025-12-28 | Lakeside Medical Group | $242.00 | Approved |
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.