CLM-2026-012019
Pinecrest Primary Care Associates, Family Medicine. Service 2026-01-29 at office (POS 11). Received 2026-02-21.
Member
Resolved through the identity graph
- Member
- Danielle Kelley
- Member ID
- UHC-50091-64
- Date of birth
- 2003-01-07
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-415040
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6344
- Coverage period
- 2023-05-01 to present
- Deductible
- $75.15 of $1,000.008%
- Out-of-pocket maximum
- $1,253.01 of $3,000.0042%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6406754658
- Network
- In network
- Rendering NPI
- 4969984481
- Location
- Tempe, AZ · TIN 31-0675839
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $259.00 | $160.58 | — | — | DeniedCO18 |
| 2 | 36415 | Venipuncture | 25 | 1 | 1,2 | $25.00 | $15.50 | — | — | DeniedCO18 |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $236.00 | $146.32 | — | — | DeniedCO18 |
| Totals | $520.00 | $322.40 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-496784
- 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-010989 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-29: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-012018: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Primary Care Associates (6406754658). | |
| 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 Primary Care Associates2026-01-29 16:24
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-02-21 00:38
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-21 16:17
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-012018: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033816 | 2026-01-19 | Canyon Reference Lab | $167.00 | Denied |
| CLM-2026-012018 | 2026-01-29 | Pinecrest Primary Care Associates | $520.00 | 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
Exact duplicate of an earlier submission.