Claims workbench/CLM-2026-018334
Professional claim · CMS-1500 · EDI 837P

CLM-2026-018334

Pinecrest GI Associates, Gastroenterology. Service 2026-03-15 at office (POS 11). Received 2026-07-02.

Denied
Billed
$213.00
1 line
Allowed
$132.06
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

Member
George Myers
Member ID
UHC-18318-35
Date of birth
1939-07-26
Identity
Verified2 records, confidence 1.00
Claim record
CLMCLM-427987
Relationship
Spouse, San Antonio, TX

Coverage and accumulators

Found by member ID

Plan
OPTIONS-PPO PPO group GRP-4173
Coverage period
2025-11-01 to present
Deductible
$750.08 of $2,500.0030%
Out-of-pocket maximum
$2,389.01 of $7,500.0032%
Copays
office $30.00, specialist $75.00, emergency $250.00
Physical therapy visits
5 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest GI Associates
Gastroenterology · taxonomy 207RG0100X
NPI
3588910497
Network
In network
Rendering NPI
5211101220
Location
Denver, CO · TIN 86-4406841
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
199214Office visit, established patient, moderate complexity—11$213.00$132.06——DeniedCO29
Totals$213.00$132.06——
Diagnoses (ICD-10-CM)
  • 1. R10.13 Epigastric painprincipal
  • 2. K21.9 Gastro-esophageal reflux disease without esophagitis
Claim header
Patient account
PA-259761
Frequency code
1 (original)
Accident
No
DRG
—
Admit / discharge
—
Landed
2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

CheckResultCodeDetail
Member identityPassAttached to MBR-014617 (verified, link confidence 1.00).
EligibilityPassActive on 2026-03-15: OPTIONS-PPO (PPO), effective 2025-11-01.
Timely filingFailCO29Received 109 days after the last date of service (limit 90).
Time limit for filing has expired
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest GI Associates (3588910497).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest GI Associates2026-03-15 15:55

    Patient seen for epigastric pain.

  • SystemSystem: Claims system2026-07-02 03:39

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-21 13:43
    Timely filing: Received 109 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity