CLM-2026-033731
Evergreen Digestive Health Center, Gastroenterology. Service 2026-05-04 at outpatient hospital (POS 22). Received 2026-05-27.
Member
Resolved through the identity graph
- Member
- Wayne Castillo
- Member ID
- UHC-95042-59
- Date of birth
- 1957-03-05
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-427481
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0218
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,225.55 of $3,500.0035%
- Out-of-pocket maximum
- $1,190.80 of $7,000.0017%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Digestive Health CenterGastroenterology · taxonomy 207RG0100X
- NPI
- 7438481310
- Network
- In network
- Rendering NPI
- 6350218684
- Location
- San Diego, CA · TIN 71-8732123
- 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 | $231.00 | $127.05 | $127.05 | $0.00 | Paid |
| Totals | $231.00 | $127.05 | $127.05 | $0.00 | ||||||
- 1. R10.13 Epigastric painprincipal
- 2. K21.9 Gastro-esophageal reflux disease without esophagitis
- Patient account
- PA-267557
- 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-032533 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-04: MEDICARE-ADV-A (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 23 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 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 Center2026-05-04 14:14
Follow-up for epigastric pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-267557.pdf8 pages
Itemised statement totalling $231.00 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-2026-013830 | 2026-09-27 | Riverside Medical Group | $312.00 | Approved |
| CLM-2026-019499 | 2026-07-07 | Desert Cardiovascular Associates | $1,540.00 | Approved |
| CLM-2026-000106 | 2026-05-22 | Heritage Physical Therapy | $291.00 | Denied |
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.