CLM-2026-031030
Evergreen Digestive Health Center, Gastroenterology. Service 2026-08-02 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Bryan Martinez
- Member ID
- UHC-39860-37
- Date of birth
- 2008-10-21
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-409760
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7553
- Coverage period
- 2022-12-01 to present
- Deductible
- $1,410.20 of $2,500.0056%
- Out-of-pocket maximum
- $1,303.76 of $7,500.0017%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 7557902468
- Location
- San Diego, CA · TIN 71-8732123
- Authorisation / referral
- PA2026014656 / 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 | $1,703.00 | $936.65 | $936.65 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $1,928.00 | $1,060.40 | $425.33 | $635.07 | Paid |
| Totals | $3,631.00 | $1,997.05 | $1,361.98 | $635.07 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. Z12.11 Encounter for screening for malignant neoplasm of colon
- Patient account
- PA-147753
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-008890 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-02: OPTIONS-PPO (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026014656 on file for 43239, 45378. | |
| 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 Center2026-08-02 12:40
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026014656_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-08-02 to 2026-10-31.
- Itemized billitemized_PA-147753.pdf4 pages
Itemised statement totalling $3631.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026191 | 2026-08-16 | Meadow Skin Care Associates | $537.00 | Approved |
| CLM-2026-017277 | 2026-02-05 | Pinecrest Clinical Laboratories | $103.00 | 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.