CLM-2026-003765
Pinecrest Medical Group, Family Medicine. Service 2026-09-03 at office (POS 11). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- James Rojas
- Member ID
- UHC-49912-59
- Date of birth
- 1946-10-27
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416596
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-4226
- Coverage period
- 2025-02-01 to present
- Deductible
- $59.68 of $1,000.006%
- Out-of-pocket maximum
- $1,058.29 of $3,000.0035%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 4930445893
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $300.00 | $186.00 | $25.00 | $161.00 | Paid |
| Totals | $300.00 | $186.00 | $25.00 | $161.00 | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-903746
- 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-027880 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-03: NULL (PPO), effective 2025-02-01. | |
| 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 (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 Group2026-09-03 15:10
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023232 | 2026-05-18 | Riverside Digestive Health Center | $243.00 | Approved |
| CLM-2026-005068 | 2026-03-18 | Canyon Skin Care Associates | $427.00 | Approved |
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.