CLM-2026-030580
Evergreen GI Associates, Gastroenterology. Service 2026-08-14 at outpatient hospital (POS 22). Received 2026-09-12.
Member
Resolved through the identity graph
- Member
- Samantha Payne
- Member ID
- UHC-99063-40
- Date of birth
- 2001-06-24
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430741
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-4094
- Coverage period
- 2022-01-01 to present
- Deductible
- $2,947.45 of $3,500.0084%
- Out-of-pocket maximum
- $1,569.92 of $14,000.0011%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 5049420420
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- none / REF200297
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 | $256.00 | $140.80 | $140.80 | $0.00 | Paid |
| Totals | $256.00 | $140.80 | $140.80 | $0.00 | ||||||
- 1. K58.0 Irritable bowel syndrome with diarrheaprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-954620
- 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-039103 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-14: CORE-HMO (HMO), effective 2022-01-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Evergreen GI Associates (1347472536). | |
| 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 GI Associates2026-08-14 14:11
Patient seen for irritable bowel syndrome with diarrhea.
Attachments
Documents received with the claim
- Itemized billitemized_PA-954620.pdf9 pages
Itemised statement totalling $256.00 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
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.