CLM-2026-003070
Pinecrest Medical Group, Family Medicine. Service 2026-04-30 at office (POS 11). Received 2026-06-25.
Member
Resolved through the identity graph
- Member
- Dennis Brown
- Member ID
- UHC-22981-87
- Date of birth
- 1944-05-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-430865
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-5047
- Coverage period
- 2025-10-01 to present
- Deductible
- $2,550.09 of $3,500.0073%
- Out-of-pocket maximum
- $1,857.72 of $14,000.0013%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7440098508
- Network
- In network
- Rendering NPI
- 6414117245
- Location
- Miami, FL · TIN 12-0288184
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $170.00 | $105.40 | — | — | Review |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $37.00 | $22.94 | — | — | Review |
| 3 | 36415 | Venipuncture | — | 1 | 1 | $17.00 | $10.54 | — | — | Review |
| Totals | $224.00 | $138.88 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-700935
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016906 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-30: MEDICARE-ADV-A (MA), effective 2025-10-01. | |
| Timely filing | Pass | Received 56 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-003069; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (7440098508). | |
| 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 Group2026-04-30 17:01
Patient seen for encounter for general adult medical examination without abnormal findings. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-06-25 03:22
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-06-25 10:56
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-003069.pdf1 page
Provider cover letter requesting replacement of CLM-2026-003069.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Replacement claim: Frequency code 7 replaces CLM-2026-003069; the original must be voided when this adjudicates.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027995 | 2026-09-02 | Northgate Cardiovascular Associates | $290.00 | Approved |
| CLM-2026-003069 | 2026-04-30 | Pinecrest Medical Group | $224.00 | Approved |
| CLM-2026-019938 | 2026-06-01 | Sunrise Cardiovascular Associates | $4,303.00 | Needs review |
| CLM-2026-009946 | 2026-04-28 | Summit Community Hospital | $2,946.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.