CLM-2026-013075
Pinecrest Medical Group, Internal Medicine. Service 2026-01-29 at office (POS 11). Received 2026-03-10.
Member
Resolved through the identity graph
- Member
- Elizabeth Pierce
- Member ID
- UHC-88301-75
- Date of birth
- 1970-02-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-431730
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8289
- Coverage period
- 2024-02-01 to present
- Deductible
- $2,133.86 of $3,500.0061%
- Out-of-pocket maximum
- $5,142.60 of $14,000.0037%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 5336212696
- Location
- Minneapolis, MN · TIN 79-7771425
- Authorisation / referral
- none / REF766794
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $239.00 | $148.18 | — | — | Review |
| Totals | $239.00 | $148.18 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. J44.9 COPD, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-483002
- 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-016008 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-29: CORE-HMO (HMO), effective 2024-02-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-013074, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (8331715671). | |
| 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 Group2026-01-29 11:16
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-10 04:23
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-10 16:41
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-013074, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003226 | 2026-09-01 | Mesa Dermatology Clinic | $292.00 | Approved |
| CLM-2026-013074 | 2026-01-29 | Canyon Internal Medicine Associates | $239.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.