Claims workbench/CLM-2026-022241

Professional claim · CMS-1500 · EDI 837P

CLM-2026-022241

Pinecrest Primary Care Associates, Family Medicine. Service 2025-12-20 at office (POS 11). Received 2026-01-17.

Denied

Billed

$794.00

3 lines

Allowed

$492.28

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Kenneth Day
Member ID: UHC-80408-04
Date of birth: 2008-07-12
Identity: Verified4 records, confidence 0.93
Claim record: CLMCLM-432604
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-3536
Coverage period: 2024-02-01 to present
Deductible: $465.41 of $2,500.0019%
Out-of-pocket maximum: $3,956.00 of $10,000.0040%
Copays: office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits: 0 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Primary Care Associates
Family Medicine · taxonomy 207Q00000X
NPI: 2725113155
Network: In network
Rendering NPI: 6381026544
Location: Los Angeles, CA · TIN 32-6244181
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	99395	Preventive visit, 18-39 years	—	1	1	$332.00	$205.84	—	—	DeniedCO18
2	99213	Office visit, established patient, low complexity	—	1	1	$170.00	$105.40	—	—	DeniedCO18
3	99214	Office visit, established patient, moderate complexity	—	1	2	$292.00	$181.04	—	—	DeniedCO18
Totals						$794.00	$492.28	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal

Claim header

Patient account: PA-281303
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-004144 (verified, link confidence 0.93).
Eligibility	Pass		Active on 2025-12-20: MEDICARE-ADV-A (MA), effective 2024-02-01.
Timely filing	Pass		Received 28 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-022240: same member, date of service, procedures and billing provider. Exact duplicate claim or service
Prior authorisation	Pass		No line requires precertification.
Provider network	Pass		In-network provider Pinecrest Primary Care Associates (2725113155).
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 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Primary Care Associates2025-12-20 11:09
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-01-17 00:04
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-17 12:24
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-022240: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-014002	2026-08-12	Harbor Medical Group	$345.00	Approved
CLM-2026-022240	2025-12-20	Pinecrest Primary Care Associates	$794.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

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

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity