CLM-2026-003881
Pinecrest Primary Care Associates, Family Medicine. Service 2026-07-21 at office (POS 11). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Kyle Silva
- Member ID
- UHC-98556-49
- Date of birth
- 1968-07-18
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420843
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group -
- Coverage period
- 2023-09-01 to 2026-07-02
- Deductible
- $525.40 of $1,000.0053%
- Out-of-pocket maximum
- $895.84 of $4,000.0022%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6406754658
- Network
- In network
- Rendering NPI
- 8375144598
- Location
- Tempe, AZ · TIN 31-0675839
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $258.00 | $159.96 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | 25 | 1 | 2 | $24.00 | $14.88 | — | — | DeniedCO27 |
| Totals | $282.00 | $174.84 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-751980
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-040888 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-21 is after coverage terminated on 2026-07-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 17 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 Primary Care Associates (6406754658). | |
| 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 Primary Care Associates2026-07-21 12:29
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-07 01:34
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-21 is after coverage terminated on 2026-07-02.
Other claims for this member
Same resolved identity
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.