CLM-2026-011085
Pinecrest Medical Group, Family Medicine. Service 2026-02-14 at office (POS 11). Received 2026-03-13.
Member
Resolved through the identity graph
- Member
- Heather Porter
- Member ID
- UHC-28711-83
- Date of birth
- 2004-08-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-408953
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6039
- Coverage period
- 2022-11-01 to 2026-02-02
- Deductible
- $1,863.93 of $2,500.0075%
- Out-of-pocket maximum
- $2,373.02 of $5,000.0047%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 7199856981
- Location
- Austin, TX · TIN 84-7440514
- 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 | 36415 | Venipuncture | — | 1 | 1 | $14.00 | $8.68 | — | — | DeniedCO27 |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 2 | $257.00 | $159.34 | — | — | DeniedCO27 |
| 3 | 90471 | Immunization administration | — | 1 | 1 | $44.00 | $27.28 | — | — | DeniedCO27 |
| Totals | $315.00 | $195.30 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-791500
- 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 | Pass | Attached to MBR-019502 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-14 is after coverage terminated on 2026-02-02. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 (5469942648). | |
| 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 Group2026-02-14 09:21
Patient seen for low back pain, unspecified.
- SystemSystem: Claims system2026-03-13 03:42
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-03-13 15:03
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-14 is after coverage terminated on 2026-02-02.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-024327 | 2026-09-01 | Pinecrest Regional Medical Center | $3,906.00 | Denied |
| CLM-2026-028444 | 2026-02-18 | Valley Primary Care Associates | $377.00 | Denied |
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.