Claims workbench/CLM-2026-010020
Professional claim · CMS-1500 · EDI 837P

CLM-2026-010020

Pinecrest Medical Group, Internal Medicine. Service 2026-09-22 at office (POS 11). Received 2026-10-09.

Approved
Billed
$69.00
1 line
Allowed
$42.78
contract rate applied
Plan pays
$12.78
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Theresa Carter
Member ID
UHC-04988-64
Date of birth
1968-12-13
Identity
Verified4 records, confidence 1.00
Claim record
CLMCLM-429398
Relationship
Self, Chandler, AZ

Coverage and accumulators

Found by member ID

Plan
UNKNOWN PPO group N/A
Coverage period
2024-01-01 to present
Deductible
$258.02 of $500.0052%
Out-of-pocket maximum
$558.56 of $1,500.0037%
Copays
office $30.00, specialist $50.00, emergency $350.00
Physical therapy visits
18 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3917182149
Network
In network
Rendering NPI
6356681885
Location
Nashville, TN · TIN 22-5526630
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$69.00$42.78$30.00$12.78Paid
Totals$69.00$42.78$30.00$12.78
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
  • 2. I10 Essential (primary) hypertension
Claim header
Patient account
PA-491998
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

CheckResultCodeDetail
Member identityPassAttached to MBR-008392 (verified, link confidence 1.00).
EligibilityPassActive on 2026-09-22: UNKNOWN (PPO), effective 2024-01-01.
Timely filingPassReceived 17 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Medical Group (3917182149).
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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Medical Group2026-09-22 13:25

    Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$69.00
Plan discount
$26.22
contracted rate
Plan paid
$12.78
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

ClaimServiceProviderBilledStatus
CLM-2026-0084512026-08-18Summit Family Practice$260.00Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved 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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity