CLM-2026-017126
Pinecrest Medical Group, Internal Medicine. Service 2026-08-31 to 2026-09-02 at inpatient hospital (POS 21). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Cynthia Ray
- Member ID
- UHC-69471-08
- Date of birth
- 2001-07-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-401835
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5790
- Coverage period
- 2021-01-01 to present
- Deductible
- $235.89 of $1,000.0024%
- Out-of-pocket maximum
- $1,267.15 of $3,000.0042%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 9770094834
- Location
- Minneapolis, MN · TIN 79-7771425
- Authorisation / referral
- none / REF231476
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 | $181.00 | $99.55 | $99.55 | $0.00 | Paid |
| Totals | $181.00 | $99.55 | $99.55 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-590483
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-31 to 2026-09-03
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016886 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-31: NAVIGATE-HMO (HMO), effective 2021-01-01. | |
| Timely filing | Pass | Received 11 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 (8331715671). | |
| 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 Group2026-09-02 10:51
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-590483.pdf4 pages
Itemised statement totalling $181.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011656 | 2026-01-29 | Canyon Heart Institute | $326.00 | Denied |
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.