Professional claim · CMS-1500 · EDI 837P
CLM-2026-004669
Pinecrest Medical Group, Internal Medicine. Service 2026-08-29 at office (POS 11). Received 2026-09-08.
Denied
Billed
$91.00
1 line
Allowed
$56.42
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Paul Lawson
- Member ID
- UHC-77158-43
- Date of birth
- 1967-01-26
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-423579
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2251
- Coverage period
- 2025-05-01 to 2026-01-25
- Deductible
- $1,871.76 of $2,500.0075%
- Out-of-pocket maximum
- $4,106.70 of $10,000.0041%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 6980182763
- Location
- Nashville, TN · TIN 22-5526630
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $91.00 | $56.42 | — | — | DeniedCO27 |
| Totals | $91.00 | $56.42 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. J44.9 COPD, unspecifiedprincipal
Claim header
- Patient account
- PA-551284
- 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-041085 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-29 is after coverage terminated on 2026-01-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 10 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 (3917182149). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2026-08-29 11:08
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-09-08 05:06
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-29 is after coverage terminated on 2026-01-25.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.