CLM-2026-003242
Pinecrest Family Practice, Family Medicine. Service 2026-06-09 at office (POS 11). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Stephanie Yang
- Member ID
- UHC-07193-28
- Date of birth
- 2002-09-03
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-429562
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4879
- Coverage period
- 2025-08-01 to present
- Deductible
- $120.86 of $500.0024%
- Out-of-pocket maximum
- $24.03 of $1,500.002%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9590925530
- Network
- In network
- Rendering NPI
- 4102387832
- Location
- Denver, CO · TIN 80-5640290
- 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 | $318.00 | $197.16 | $30.00 | $167.16 | Paid |
| Totals | $318.00 | $197.16 | $30.00 | $167.16 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-459971
- 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-020171 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-09: MEDICARE-ADV-A (MA), effective 2025-08-01. | |
| Timely filing | Pass | Received 28 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 Family Practice (9590925530). | |
| 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 Family Practice2026-06-09 13:31
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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.