CLM-2026-021679
Pinecrest Primary Care Associates, Family Medicine. Service 2026-04-14 at office (POS 11). Received 2026-05-29.
Member
Resolved through the identity graph
- Member
- Valentina Simmons
- Member ID
- UHC-46999-92
- Date of birth
- 1941-12-10
- Identity
- Verified2 records, confidence 0.96
- Claim record
- CLMCLM-431653
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1836
- Coverage period
- 2021-07-01 to present
- Deductible
- $938.41 of $1,500.0063%
- Out-of-pocket maximum
- $1,339.04 of $3,000.0045%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6406754658
- Network
- In network
- Rendering NPI
- 7740210456
- Location
- Tempe, AZ · TIN 31-0675839
- 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 | $16.00 | $9.92 | $9.92 | $0.00 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | — | 1 | 1,2 | $186.00 | $115.32 | $0.00 | $115.32 | Paid |
| Totals | $202.00 | $125.24 | $9.92 | $115.32 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. Z00.00 Encounter for general adult medical examination without abnormal findings
- Patient account
- PA-969052
- 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-020518 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-04-14: NAVIGATE-HMO (HMO), effective 2021-07-01. | |
| Timely filing | Pass | Received 45 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 Primary Care Associates (6406754658). | |
| 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 Primary Care Associates2026-04-14 15:18
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010932 | 2026-02-01 | Lakeside Digestive Health Center | $317.00 | Approved |
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.