CLM-2026-016343
Pinecrest Medical Group, Family Medicine. Service 2026-08-08 at office (POS 11). Received 2026-09-21.
Member
Resolved through the identity graph
- Member
- Sophia Carroll
- Member ID
- UHC-64413-52
- Date of birth
- 1979-02-23
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-406610
- Relationship
- Child, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7932
- Coverage period
- 2023-12-01 to 2026-03-12
- Deductible
- $962.16 of $2,500.0038%
- Out-of-pocket maximum
- $1,728.42 of $5,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2732475423
- Network
- In network
- Rendering NPI
- 3832675839
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $189.00 | $117.18 | — | — | DeniedCO27 |
| Totals | $189.00 | $117.18 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-819497
- 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-009374 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-08 is after coverage terminated on 2026-03-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 44 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 (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 Group2026-08-08 12:40
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-21 02:31
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-21 13:01
Member services inquiry logged on this claim; member asked about the status of payment.
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 2026-08-08 is after coverage terminated on 2026-03-12.
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.