CLM-2026-015379
Pinecrest Medical Group, Family Medicine. Service 2025-12-20 at office (POS 11). Received 2026-01-11.
Member
Resolved through the identity graph
- Member
- Jose Lane
- Member ID
- UHC-08690-20
- Date of birth
- 1969-10-15
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401358
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-1121
- Coverage period
- 2023-10-01 to present
- Deductible
- $1,882.86 of $2,500.0075%
- Out-of-pocket maximum
- $3,246.14 of $7,500.0043%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2732475423
- Network
- In network
- Rendering NPI
- 4218031266
- Location
- Tempe, AZ · TIN 64-9893800
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $260.00 | $161.20 | — | — | Review |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $44.00 | $27.28 | — | — | Review |
| Totals | $304.00 | $188.48 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-703590
- 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-000290 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-20: - (PPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-015378, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (2732475423). | |
| 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 Group2025-12-20 09:36
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-01-11 04:09
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
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-2026-015378, billed by a different provider.
- AI recommendationPended2026-10-23 17:08The claim appears to be a duplicate of CLM-2026-015378, which was already approved for the same member and date of service. The rules engine flagged this as a possible duplicate (DUP). The examiner should verify which claim is the correct one and void the other.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · d542f0d2
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:08 · 189b0451
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015378 | 2025-12-20 | Cornerstone Family Practice | $304.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- DUP Possible duplicate
The claim appears to be a duplicate of CLM-2026-015378, which was already approved for the same member and date of service. The rules engine flagged this as a possible duplicate (DUP). The examiner should verify which claim is the correct one and void the other.
- Verify if this is a duplicate claim and if so, which claim should be voided.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- DUP Possible duplicate
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.