CLM-2026-009107
Pinecrest Family Practice, Family Medicine. Service 2026-06-18 at office (POS 11). Received 2026-06-26.
Member
Resolved through the identity graph
- Member
- Christina Cooper
- Member ID
- UHC-08660-19
- Date of birth
- 1958-05-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-432448
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0479
- Coverage period
- 2023-06-01 to 2026-02-25
- Deductible
- $1,894.76 of $2,500.0076%
- Out-of-pocket maximum
- $1,421.09 of $5,000.0028%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9590925530
- Network
- In network
- Rendering NPI
- 1326281155
- 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 | 90471 | Immunization administration | — | 1 | 1 | $32.00 | $19.84 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $246.00 | $152.52 | — | — | DeniedCO27 |
| Totals | $278.00 | $172.36 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-276466
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007497 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-18 is after coverage terminated on 2026-02-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 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 Practice2026-06-18 09:15
Follow-up for type 2 diabetes mellitus without complications. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-26 06:27
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-18 is after coverage terminated on 2026-02-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001178 | 2026-01-22 | Mesa Internal Medicine Associates | $209.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.