CLM-2026-015548
Pinecrest Medical Group, Family Medicine. Service 2026-07-13 at office (POS 11). Received 2026-07-20.
Member
Resolved through the identity graph
- Member
- Marcus Herrera
- Member ID
- none on golden record
- Date of birth
- 1956-12-27
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-426299
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by name and date of birth
- Plan
- NULL PPO group GRP-5131
- Coverage period
- 2023-11-01 to 2026-04-21
- Deductible
- $51.04 of $500.0010%
- Out-of-pocket maximum
- $857.52 of $2,000.0043%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 6878777799
- 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 | 90471 | Immunization administration | — | 1 | 1 | $45.00 | $27.90 | — | — | DeniedCO27 |
| 2 | 36415 | Venipuncture | — | 1 | 2 | $22.00 | $13.64 | — | — | DeniedCO27 |
| Totals | $67.00 | $41.54 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-160282
- 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-021676 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-13 is after coverage terminated on 2026-04-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 15:22
Established patient presents with hyperlipidemia, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-20 04:29
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-13 is after coverage terminated on 2026-04-21.
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.