Professional claim · CMS-1500 · EDI 837P
CLM-2026-020263
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2026-06-30 at office (POS 11). Received 2026-07-13.
Approved
Billed
$529.00
3 lines
Allowed
$327.98
contract rate applied
Plan pays
$297.98
approved
Member owes
$30.00
copay / deductible / 20% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Samantha Olson
- Member ID
- UHC-70649-18
- Date of birth
- 1980-08-18
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-418051
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6248
- Coverage period
- 2021-12-01 to present
- Deductible
- $451.87 of $1,500.0030%
- Out-of-pocket maximum
- $1,101.85 of $3,000.0037%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9530324190
- Network
- In network
- Rendering NPI
- 9320939850
- Location
- Charlotte, NC · TIN 19-6063238
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $332.00 | $205.84 | $30.00 | $175.84 | Paid |
| 2 | 93000 | Electrocardiogram with interpretation | — | 1 | 2 | $118.00 | $73.16 | $0.00 | $73.16 | Paid |
| 3 | 80053 | Comprehensive metabolic panel | — | 1 | 2 | $79.00 | $48.98 | $0.00 | $48.98 | Paid |
| Totals | $529.00 | $327.98 | $30.00 | $297.98 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- 2. I10 Essential (primary) hypertension
- 3. J44.9 COPD, unspecified
Claim header
- Patient account
- PA-316258
- 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
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009467 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-30: MEDICARE-ADV-B (MA), effective 2021-12-01. | |
| Timely filing | Pass | Received 13 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 Internal Medicine Associates (9530324190). | |
| 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. |
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 Internal Medicine Associates2026-06-30 17:13
Follow-up for type 2 diabetes mellitus with hyperglycemia. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$529.00
Plan discount
$201.02
contracted rate
Plan paid
$297.98
You may owe
$30.00
copay, deductible and coinsurance
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025230 | 2026-08-24 | Lakeside Skin Care Associates | $688.00 | Approved |
| CLM-2026-020264 | 2026-06-30 | Pinecrest Internal Medicine Associates | $529.00 | Denied |
| CLM-2026-008167 | 2026-06-19 | Lakeside Physical Therapy | $521.00 | Approved |
| CLM-2026-009080 | 2026-02-27 | Summit Counseling Center | $284.00 | Denied |
| CLM-2026-009079 | 2026-02-27 | Summit Counseling Center | $284.00 | Approved |
| CLM-2026-021153 | 2025-12-20 | Summit Medical Group | $166.00 | Approved |
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.