CLM-2026-016222
Pinecrest Medical Group, Internal Medicine. Service 2026-05-14 to 2026-05-16 at inpatient hospital (POS 21). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Paul Riley
- Member ID
- UHC-16469-58
- Date of birth
- 1973-02-14
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-420271
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5564
- Coverage period
- 2022-11-01 to present
- Deductible
- $2,142.41 of $2,500.0086%
- Out-of-pocket maximum
- $1,602.13 of $7,500.0021%
- Copays
- office $30.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3001804152
- Network
- In network
- Rendering NPI
- 7639553362
- Location
- Dallas, TX · TIN 55-8186699
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $187.00 | $102.85 | $102.85 | $0.00 | Paid |
| Totals | $187.00 | $102.85 | $102.85 | $0.00 | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-782707
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-05-14 to 2026-05-18
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015117 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-14: OPTIONS-PPO (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 6 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 (3001804152). | |
| 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 Group2026-05-16 16:06
Follow-up for copd, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-782707.pdf7 pages
Itemised statement totalling $187.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023876 | 2026-02-27 | Mesa Bone and Joint Center | $8,006.00 | Approved |
| CLM-2026-033485 | 2026-03-01 | Sunrise Cardiovascular Associates | $383.00 | Approved |
| CLM-2026-008437 | 2026-02-01 | Meadow Physical Therapy | $5,036.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.