CLM-2026-001788
Pinecrest Medical Group, Internal Medicine. Service 2026-08-30 at office (POS 11). Received 2026-09-30.
Member
Resolved through the identity graph
- Member
- Michelle Kennedy
- Member ID
- UHC-59953-53
- Date of birth
- 1967-01-05
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-409016
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1450
- Coverage period
- 2023-06-01 to 2026-07-05
- Deductible
- $286.14 of $500.0057%
- Out-of-pocket maximum
- $440.89 of $2,000.0022%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 6822311992
- Location
- Minneapolis, MN · TIN 79-7771425
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $394.00 | $244.28 | — | — | DeniedCO27 |
| Totals | $394.00 | $244.28 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-159984
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014323 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-30 is after coverage terminated on 2026-07-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 31 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 Pinecrest Medical Group (8331715671). | |
| 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 Medical Group2026-08-30 09:44
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-30 05:48
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-30 is after coverage terminated on 2026-07-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031246 | 2026-06-19 | Meadow Internal Medicine Associates | $89.00 | 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
Service after coverage termination.