CLM-2026-021406
Pinecrest Medical Group, Internal Medicine. Service 2026-03-10 at office (POS 11). Received 2026-10-05.
Member
Resolved through the identity graph
- Member
- Wei Fields
- Member ID
- UHC-62961-20
- Date of birth
- 1959-12-24
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-421938
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4190
- Coverage period
- 2025-03-01 to present
- Deductible
- $447.30 of $500.0089%
- Out-of-pocket maximum
- $177.95 of $1,000.0018%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 5141665419
- Location
- Nashville, TN · TIN 22-5526630
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $109.00 | $67.58 | — | — | DeniedCO29 |
| 2 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $63.00 | $39.06 | — | — | DeniedCO29 |
| 3 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $361.00 | $223.82 | — | — | DeniedCO29 |
| Totals | $533.00 | $330.46 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-764731
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-012283 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: MEDICARE-ADV-B (MA), effective 2025-03-01. | |
| Timely filing | Fail | CO29 | Received 209 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3917182149). | |
| 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 Group2026-03-10 10:04
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-05 03:10
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 209 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025069 | 2026-09-07 | Valley Regional Medical Center | $217.00 | Approved |
| CLM-2026-007764 | 2026-06-21 | Lakeside Dermatology Clinic | $742.00 | Approved |
| CLM-2026-010560 | 2026-04-21 | Lakeside Reference Lab | $120.00 | Approved |
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
Received after the timely-filing limit.