CLM-2026-017615
Pinecrest Medical Group, Family Medicine. Service 2026-04-14 at office (POS 11). Received 2026-04-16.
Member
Resolved through the identity graph
- Member
- Dylan Foster
- Member ID
- UHC-84539-43
- Date of birth
- 1970-07-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409972
- Relationship
- Spouse, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1877
- Coverage period
- 2023-05-01 to 2026-04-15
- Deductible
- $1,478.54 of $3,500.0042%
- Out-of-pocket maximum
- $2,611.00 of $14,000.0019%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 2114752696
- Location
- Austin, TX · TIN 84-7440514
- 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 | 99395 | Preventive visit, 18-39 years | — | 1 | 1 | $249.00 | $154.38 | $30.00 | $124.38 | Paid |
| 2 | 36415 | Venipuncture | — | 1 | 1 | $12.00 | $7.44 | $0.00 | $7.44 | Paid |
| 3 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $258.00 | $159.96 | $0.00 | $159.96 | Paid |
| Totals | $519.00 | $321.78 | $30.00 | $291.78 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-357159
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-018096 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-14: NAVIGATE-HMO (HMO), effective 2023-05-01, terms 2026-04-15. | |
| Timely filing | Pass | Received 2 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 (5469942648). | |
| 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 Group2026-04-14 11:55
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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-2026-007656 | 2026-06-11 | Desert Diabetes Center | $328.00 | 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.