CLM-2026-006898
Pinecrest Medical Group, Internal Medicine. Service 2025-12-19 to 2025-12-20 at inpatient hospital (POS 21). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Beverly Padilla
- Member ID
- UHC-35803-15
- Date of birth
- 1954-10-26
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-407732
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1644
- Coverage period
- 2024-10-01 to present
- Deductible
- $568.90 of $3,500.0016%
- Out-of-pocket maximum
- $184.59 of $14,000.001%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 4188780694
- Location
- Nashville, TN · TIN 22-5526630
- Authorisation / referral
- none / REF388643
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $215.00 | $118.25 | $118.25 | $0.00 | Paid |
| Totals | $215.00 | $118.25 | $118.25 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-578818
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-19 to 2025-12-23
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004517 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: CORE-HMO (HMO), effective 2024-10-01. | |
| Timely filing | Pass | Received 26 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2025-12-20 13:59
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-578818.pdf4 pages
Itemised statement totalling $215.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-000704 | 2026-03-09 | Sunrise Diagnostic Imaging | $1,577.00 | Approved |
| CLM-2026-016288 | 2026-01-08 | Valley Cardiovascular Associates | $8,562.00 | 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.