Claims workbench/CLM-2026-008407
Professional claim · CMS-1500 · EDI 837P

CLM-2026-008407

Pinecrest Family Practice, Family Medicine. Service 2026-09-03 at office (POS 11). Received 2026-09-29.

Denied
Billed
$25.00
1 line
Allowed
$15.50
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
Diana Cruz
Member ID
UHC-19574-09
Date of birth
1984-05-15
Identity
Verified3 records, confidence 1.00
Claim record
CLMCLM-430886
Relationship
Self, Orlando, FL

Coverage and accumulators

Found by member ID

Plan
NAVIGATE-HMO HMO group GRP-4448
Coverage period
2024-10-01 to 2026-04-20
Deductible
$95.01 of $500.0019%
Out-of-pocket maximum
$837.97 of $2,000.0042%
Copays
office $30.00, specialist $75.00, emergency $150.00
Physical therapy visits
4 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Family Practice
Family Medicine · taxonomy 207Q00000X
NPI
9590925530
Network
In network
Rendering NPI
8612212224
Location
Denver, CO · TIN 80-5640290
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
136415Venipuncture—11$25.00$15.50——DeniedCO27
Totals$25.00$15.50——
Diagnoses (ICD-10-CM)
  • 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
  • 2. M54.50 Low back pain, unspecified
Claim header
Patient account
PA-696252
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-021903 (verified, link confidence 1.00).
EligibilityFailCO27Date of service 2026-09-03 is after coverage terminated on 2026-04-20.
Expenses incurred after coverage terminated
Timely filingPassReceived 26 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Family Practice (9590925530).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Family Practice2026-09-03 18:08

    Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-09-29 02:10

  • AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-29 13:32

    Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Eligibility: Date of service 2026-09-03 is after coverage terminated on 2026-04-20.

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.

Review queueMember identity