CLM-2026-002526
Pinecrest Medical Group, Family Medicine. Service 2026-08-14 at office (POS 11). Received 2026-10-03.
Member
Resolved through the identity graph
- Member
- Noah Soto
- Member ID
- UHC-40906-06
- Date of birth
- 1959-04-28
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-428193
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6628
- Coverage period
- 2021-09-01 to present
- Deductible
- $804.07 of $3,500.0023%
- Out-of-pocket maximum
- $2,877.31 of $10,500.0027%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 1505409866
- Location
- Austin, TX · TIN 84-7440514
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $202.00 | $125.24 | — | — | DeniedCO18 |
| Totals | $202.00 | $125.24 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-827375
- 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-034498 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-14: MEDICARE-ADV-B (MA), effective 2021-09-01. | |
| Timely filing | Pass | Received 50 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-002525: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (5469942648). | |
| 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 Group2026-08-14 18:08
Patient seen for acute upper respiratory infection, unspecified.
- SystemSystem: Claims system2026-10-03 01:15
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-002525: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002525 | 2026-08-14 | Pinecrest Medical Group | $202.00 | 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
Exact duplicate of an earlier submission.