CLM-2026-012539
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2026-05-07 to 2026-05-08 at inpatient hospital (POS 21). Received 2026-06-17.
Member
Resolved through the identity graph
- Member
- Mateo Perez
- Member ID
- UHC-46817-61
- Date of birth
- 2003-01-14
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-414521
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7687
- Coverage period
- 2021-11-01 to present
- Deductible
- $1,048.33 of $2,500.0042%
- Out-of-pocket maximum
- $1,297.22 of $7,500.0017%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9530324190
- Network
- In network
- Rendering NPI
- 9029732788
- Location
- Charlotte, NC · TIN 19-6063238
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $189.00 | $103.95 | $103.95 | $0.00 | Paid |
| Totals | $189.00 | $103.95 | $103.95 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-992771
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-07 to 2026-05-11
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017686 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-07: NAVIGATE-HMO (HMO), effective 2021-11-01. | |
| Timely filing | Pass | Received 40 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 Internal Medicine Associates (9530324190). | |
| 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 Internal Medicine Associates2026-05-08 12:30
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-992771.pdf5 pages
Itemised statement totalling $189.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034284 | 2026-09-23 | Meadow Diagnostic Imaging | $3,143.00 | Denied |
| CLM-2026-003467 | 2026-08-07 | Evergreen Internal Medicine Associates | $271.00 | Needs review |
| CLM-2026-003466 | 2026-08-07 | Evergreen Internal Medicine Associates | $271.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.