Claims workbench/CLM-2026-018676
Professional claim · CMS-1500 · EDI 837P

CLM-2026-018676

Pinecrest Medical Group, Internal Medicine. Service 2026-08-11 at office (POS 11). Received 2026-09-05.

Approved
Billed
$99.00
1 line
Allowed
$61.38
contract rate applied
Plan pays
$31.38
approved
Member owes
$30.00
copay / deductible / 10% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Anthony Morrison
Member ID
UHC-63513-43
Date of birth
1987-09-13
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-432302
Relationship
Child, Tucson, AZ

Coverage and accumulators

Found by member ID

Plan
SELECT-EPO EPO group GRP-6864
Coverage period
2021-03-01 to present
Deductible
$327.58 of $500.0066%
Out-of-pocket maximum
$117.31 of $2,000.006%
Copays
office $30.00, specialist $60.00, emergency $150.00
Physical therapy visits
9 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
8331715671
Network
In network
Rendering NPI
8041612762
Location
Minneapolis, MN · TIN 79-7771425
Authorisation / referral
none / none

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193000Electrocardiogram with interpretation—11$99.00$61.38$30.00$31.38Paid
Totals$99.00$61.38$30.00$31.38
Diagnoses (ICD-10-CM)
  • 1. I10 Essential (primary) hypertensionprincipal
  • 2. J44.9 COPD, unspecified
Claim header
Patient account
PA-187651
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

CheckResultCodeDetail
Member identityPassAttached to MBR-039544 (verified, link confidence 0.99).
EligibilityPassActive on 2026-08-11: SELECT-EPO (EPO), effective 2021-03-01.
Timely filingPassReceived 25 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Medical Group (8331715671).
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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Medical Group2026-08-11 16:01

    Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

No attachments.

Explanation of benefits

What the member will see

Amount billed
$99.00
Plan discount
$37.62
contracted rate
Plan paid
$31.38
You may owe
$30.00
copay, deductible and coinsurance

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineApproved2026-10-22 12:44
    Clean claim.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

Clean claim: the rules engine approved it, so no AI review was needed.

Examiner decision

Approved 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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queueMember identity