CLM-2026-017646
Pinecrest Medical Group, Internal Medicine. Service 2026-06-18 to 2026-06-19 at inpatient hospital (POS 21). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Austin Riley
- Member ID
- UHC-82443-76
- Date of birth
- 1992-12-27
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-405770
- Relationship
- Child, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7961
- Coverage period
- 2022-07-01 to 2026-04-21
- Deductible
- $303.15 of $1,500.0020%
- Out-of-pocket maximum
- $2,121.26 of $4,500.0047%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 3630947141
- Location
- Minneapolis, MN · TIN 79-7771425
- 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 | $180.00 | $99.00 | — | — | DeniedCO27 |
| Totals | $180.00 | $99.00 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-878949
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-06-18 to 2026-06-19
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014595 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-18 is after coverage terminated on 2026-04-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 39 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 Group2026-06-19 14:24
Patient seen for type 2 diabetes mellitus with hyperglycemia.
- SystemSystem: Claims system2026-07-28 01:19
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-28 12:17
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-878949.pdf4 pages
Itemised statement totalling $180.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-18 is after coverage terminated on 2026-04-21.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014898 | 2026-03-25 | Pinecrest Regional Medical Center | $936.00 | 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
Service after coverage termination.