CLM-2026-019180
Pinecrest Medical Group, Family Medicine. Service 2026-03-05 at office (POS 11). Received 2026-04-14.
Member
Resolved through the identity graph
- Member
- Walter Estrada
- Member ID
- UHC-13603-42
- Date of birth
- 1987-03-07
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-400283
- Relationship
- Spouse, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5648
- Coverage period
- 2023-09-01 to 2026-01-17
- Deductible
- $432.16 of $500.0086%
- Out-of-pocket maximum
- $426.35 of $2,000.0021%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7440098508
- Network
- In network
- Rendering NPI
- 1442120410
- Location
- Miami, FL · TIN 12-0288184
- 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 | 36415 | Venipuncture | — | 1 | 1 | $13.00 | $8.06 | — | — | DeniedCO27 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $285.00 | $176.70 | — | — | DeniedCO27 |
| Totals | $298.00 | $184.76 | — | — | ||||||
- 1. J06.9 Acute upper respiratory infection, unspecifiedprincipal
- Patient account
- PA-783487
- 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-025769 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-05 is after coverage terminated on 2026-01-17. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 40 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 (7440098508). | |
| 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 Group2026-03-05 10:29
Follow-up for acute upper respiratory infection, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-14 04:23
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-14 10:58
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 engineDenied2026-10-22 12:44Eligibility: Date of service 2026-03-05 is after coverage terminated on 2026-01-17.
Other claims for this member
Same resolved identity
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.