CLM-2026-034230
Pinecrest GI Associates, Gastroenterology. Service 2026-01-28 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Fatima Taylor
- Member ID
- UHC-67995-68
- Date of birth
- 1979-11-28
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-401658
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9269
- Coverage period
- 2024-04-01 to present
- Deductible
- $1,333.41 of $3,500.0038%
- Out-of-pocket maximum
- $270.30 of $7,000.004%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 3588910497
- Network
- In network
- Rendering NPI
- 7007230239
- Location
- Denver, CO · TIN 86-4406841
- Authorisation / referral
- PA2026890778 / 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 | $2,240.00 | $1,232.00 | $1,232.00 | $0.00 | Paid |
| 2 | 45378 rev 0750 | Colonoscopy, diagnostic | — | 1 | 1 | $2,695.00 | $1,482.25 | $1,044.12 | $438.13 | Paid |
| Totals | $4,935.00 | $2,714.25 | $2,276.12 | $438.13 | ||||||
- 1. R10.13 Epigastric painprincipal
- Patient account
- PA-267351
- 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-013422 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-28: SELECT-EPO (EPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026890778 on file for 43239, 45378. | |
| 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 Associates2026-01-28 17:54
Patient seen for epigastric pain.
Attachments
Documents received with the claim
- Prior auth letterPA2026890778_approval.pdf2 pages
Utilisation management approval letter for 43239 (Upper GI endoscopy with biopsy), valid 2026-01-28 to 2026-04-28.
- Itemized billitemized_PA-267351.pdf6 pages
Itemised statement totalling $4935.00 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
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.