CLM-2026-015680
Pinecrest Behavioral Health, Behavioral Health. Service 2026-08-27 at office (POS 11). Received 2026-08-30.
Member
Resolved through the identity graph
- Member
- Christine Jimenez
- Member ID
- UHC-90658-11
- Date of birth
- 2000-08-25
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-420163
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-2075
- Coverage period
- 2025-12-01 to 2026-06-25
- Deductible
- $368.05 of $1,500.0025%
- Out-of-pocket maximum
- $193.10 of $3,000.006%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 1343492496
- Location
- Nashville, TN · TIN 20-1333588
- 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 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 1 | $441.00 | $273.42 | — | — | DeniedCO27 |
| 2 | 90834 | Psychotherapy, 45 minutes | 25 | 1 | 1 | $142.00 | $88.04 | — | — | DeniedCO27 |
| Totals | $583.00 | $361.46 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-852759
- 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-024586 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-27 is after coverage terminated on 2026-06-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Behavioral Health (2968932766). | |
| 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 Behavioral Health2026-08-27 15:21
Established patient presents with post-traumatic stress disorder, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-08-30 02:29
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-30 14:39
Called the provider office; awaiting documentation.
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 2026-08-27 is after coverage terminated on 2026-06-25.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001032 | 2026-03-24 | Desert Primary Care Associates | $726.00 | Approved |
| CLM-2026-030742 | 2026-03-02 | Sunrise Digestive Health Center | $4,649.00 | Approved |
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.