CLM-2026-006713
Pinecrest Primary Care Associates, Family Medicine. Service 2026-01-03 at office (POS 11). Received 2026-01-24.
Member
Resolved through the identity graph
- Member
- Jean Walsh
- Member ID
- UHC-14913-65
- Date of birth
- 1949-10-02
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-404170
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1699
- Coverage period
- 2023-10-01 to present
- Deductible
- $77.22 of $1,500.005%
- Out-of-pocket maximum
- $24.91 of $4,500.001%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2725113155
- Network
- In network
- Rendering NPI
- 4679696805
- Location
- Los Angeles, CA · TIN 32-6244181
- 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 | 36415 | Venipuncture | — | 1 | 1 | $24.00 | $14.88 | $14.88 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1,2 | $283.00 | $175.46 | $0.00 | $175.46 | Paid |
| 3 | 90471 | Immunization administration | — | 1 | 2 | $25.00 | $15.50 | $0.00 | $15.50 | Paid |
| Totals | $332.00 | $205.84 | $14.88 | $190.96 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-195277
- 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-007179 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-03: MEDICARE-ADV-A (MA), effective 2023-10-01. | |
| Timely filing | Pass | Received 21 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 (2725113155). | |
| 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 Associates2026-01-03 18:30
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.