CLM-2026-014543
Pinecrest Medical Group, Family Medicine. Service 2026-07-13 at office (POS 11). Received 2026-07-18.
Member
Resolved through the identity graph
- Member
- Danielle Martinez
- Member ID
- UHC-78916-82
- Date of birth
- 2004-07-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-422508
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-5428
- Coverage period
- 2024-02-01 to 2026-03-15
- Deductible
- $412.27 of $500.0082%
- Out-of-pocket maximum
- $500.85 of $1,500.0033%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 5079686411
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $149.00 | $92.38 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | 25 | 1 | 2 | $34.00 | $21.08 | — | — | DeniedCO27 |
| Totals | $183.00 | $113.46 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-307577
- 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-009172 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-13 is after coverage terminated on 2026-03-15. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Group2026-07-13 09:42
Established patient presents with acute upper respiratory infection, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-18 01:59
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-18 10:55
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 engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-13 is after coverage terminated on 2026-03-15.
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.