CLM-2026-008914
Pinecrest Family Practice, Family Medicine. Service 2026-07-29 at office (POS 11). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Pamela Sanders
- Member ID
- UHC-11818-05
- Date of birth
- 1960-06-02
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416671
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-2117
- Coverage period
- 2021-09-01 to present
- Deductible
- $1,044.38 of $1,500.0070%
- Out-of-pocket maximum
- $1,505.64 of $4,500.0033%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9590925530
- Network
- In network
- Rendering NPI
- 1368847608
- Location
- Denver, CO · TIN 80-5640290
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $283.00 | $175.46 | — | — | PendedIDQ |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $152.00 | $94.24 | — | — | PendedIDQ |
| 3 | 90471 | Immunization administration | 25 | 1 | 1 | $35.00 | $21.70 | — | — | PendedIDQ |
| Totals | $470.00 | $291.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- 3. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-998640
- 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 | Fail | IDQ | Member record is in open steward case CASE-003033; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-07-29: N/A (PPO), effective 2021-09-01. | |
| Timely filing | Pass | Received 9 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 Family Practice (9590925530). | |
| 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 Family Practice2026-07-29 14:39
Patient seen for encounter for general adult medical examination without abnormal findings.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003033; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.