CLM-2026-018362
Pinecrest Medical Group, Internal Medicine. Service 2026-06-23 at office (POS 11). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Jerry Ramirez
- Member ID
- UHC-59013-51
- Date of birth
- 1968-11-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413152
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7197
- Coverage period
- 2021-11-01 to 2026-07-03
- Deductible
- $2.74 of $3,500.000%
- Out-of-pocket maximum
- $585.93 of $7,000.008%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 9449973434
- Location
- Nashville, TN · TIN 22-5526630
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $303.00 | $187.86 | — | — | Review |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $88.00 | $54.56 | — | — | Review |
| Totals | $391.00 | $242.42 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-987168
- 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-028948 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: CHOICE-PLUS-PPO (PPO), effective 2021-11-01, terms 2026-07-03. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-018361, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (3917182149). | |
| 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 Group2026-06-23 15:25
Patient seen for chronic kidney disease, stage 3 unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-07-15 00:28
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-15 11:47
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 engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-018361, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018361 | 2026-06-23 | Pinecrest Medical Group | $391.00 | Approved |
| CLM-2026-019446 | 2026-04-15 | Meadow GI Associates | $220.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Different billing provider; separately payable.