CLM-2026-017090
Pinecrest Medical Group, Family Medicine. Service 2026-03-17 at office (POS 11). Received 2026-08-18.
Member
Resolved through the identity graph
- Member
- Margaret Bryant
- Member ID
- UHC-57103-48
- Date of birth
- 1978-09-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419473
- Relationship
- Spouse, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7627
- Coverage period
- 2025-08-01 to present
- Deductible
- $142.20 of $500.0028%
- Out-of-pocket maximum
- $326.63 of $2,000.0016%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2732475423
- Network
- In network
- Rendering NPI
- 4142085768
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $188.00 | $116.56 | — | — | DeniedCO29 |
| Totals | $188.00 | $116.56 | — | — | ||||||
- 1. E78.5 Hyperlipidemia, unspecifiedprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-882067
- 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-017395 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-17: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Fail | CO29 | Received 154 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Group2026-03-17 13:33
Follow-up for hyperlipidemia, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-08-18 03:29
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-18 15:06
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 154 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015003 | 2026-06-01 | Mesa Clinical Laboratories | $145.00 | Approved |
| CLM-2026-019886 | 2026-03-27 | Meadow Medical Group | $1,883.00 | Needs review |
| CLM-2026-020874 | 2026-01-25 | Pinecrest Physical Therapy | $525.00 | 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
Received after the timely-filing limit.