CLM-2026-020691
Pinecrest Medical Group, Internal Medicine. Service 2026-03-25 to 2026-03-26 at inpatient hospital (POS 21). Received 2026-04-15.
Member
Resolved through the identity graph
- Member
- Sara Richardson
- Member ID
- UHC-63949-90
- Date of birth
- 1969-10-24
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-432640
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-7806
- Coverage period
- 2022-07-01 to present
- Deductible
- $65.92 of $1,000.007%
- Out-of-pocket maximum
- $1,008.97 of $4,000.0025%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 2974845507
- Location
- Minneapolis, MN · TIN 79-7771425
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $253.00 | $139.15 | $139.15 | $0.00 | Paid |
| Totals | $253.00 | $139.15 | $139.15 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- Patient account
- PA-426287
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-25 to 2026-03-29
- 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-019132 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-25: NULL (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 20 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 (8331715671). | |
| 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 Group2026-03-26 18:05
Patient seen for chronic kidney disease, stage 3 unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-426287.pdf2 pages
Itemised statement totalling $253.00 across 1 line.
Explanation of benefits
What the member will see
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
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.