CLM-2026-018789
Pinecrest Medical Group, Internal Medicine. Service 2026-03-26 at office (POS 11). Received 2026-04-01.
Member
Resolved through the identity graph
- Member
- Gabriel Patel
- Member ID
- UHC-90961-55
- Date of birth
- 1973-07-01
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-430202
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6176
- Coverage period
- 2022-08-01 to present
- Deductible
- $553.10 of $1,500.0037%
- Out-of-pocket maximum
- $229.26 of $3,000.008%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3001804152
- Network
- In network
- Rendering NPI
- 1547910186
- Location
- Dallas, TX · TIN 55-8186699
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $52.00 | $32.24 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $385.00 | $238.70 | — | — | Review |
| 3 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $283.00 | $175.46 | — | — | Review |
| Totals | $720.00 | $446.40 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-629785
- 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-019824 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-26: MEDICARE-ADV-A (MA), effective 2022-08-01. | |
| Timely filing | Pass | Received 6 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 (3001804152). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2026-03-26 16:25
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-04-01 03:27
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-04-01 11:32
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications rec”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.