CLM-2026-014518
Pinecrest Medical Group, Family Medicine. Service 2026-09-18 at office (POS 11). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- George Fernandez
- Member ID
- UHC-94231-07
- Date of birth
- 1951-05-09
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-403009
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0655
- Coverage period
- 2023-08-01 to 2026-06-04
- Deductible
- $319.76 of $500.0064%
- Out-of-pocket maximum
- $306.46 of $2,000.0015%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7440098508
- Network
- In network
- Rendering NPI
- 4992900462
- Location
- Miami, FL · TIN 12-0288184
- 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 | 90471 | Immunization administration | — | 1 | 1 | $31.00 | $19.22 | — | — | DeniedCO27 |
| Totals | $31.00 | $19.22 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-252029
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003345 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-18 is after coverage terminated on 2026-06-04. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 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 (7440098508). | |
| 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 Group2026-09-18 17:42
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-10-10 02:47
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-18 is after coverage terminated on 2026-06-04.
Other claims for this member
Same resolved identity
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.