Professional claim · CMS-1500 · EDI 837P
CLM-2026-022520
Pinecrest Primary Care Associates, Family Medicine. Service 2026-08-26 at office (POS 11). Received 2026-09-12.
Approved
Billed
$515.00
2 lines
Allowed
$319.30
contract rate applied
Plan pays
$289.30
approved
Member owes
$30.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Sofia Mitchell
- Member ID
- UHC-25956-67
- Date of birth
- 1969-05-08
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-427561
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-3016
- Coverage period
- 2021-04-01 to present
- Deductible
- $99.04 of $500.0020%
- Out-of-pocket maximum
- $287.88 of $1,500.0019%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2725113155
- Network
- In network
- Rendering NPI
- 4362626796
- 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 | $337.00 | $208.94 | $30.00 | $178.94 | Paid |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $178.00 | $110.36 | $0.00 | $110.36 | Paid |
| Totals | $515.00 | $319.30 | $30.00 | $289.30 | ||||||
Diagnoses (ICD-10-CM)
- 1. I10 Essential (primary) hypertensionprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
Claim header
- Patient account
- PA-523630
- 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-008120 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-26: OPTIONS-PPO (PPO), effective 2021-04-01. | |
| Timely filing | Pass | Received 17 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 (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 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Primary Care Associates2026-08-26 12:20
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$515.00
Plan discount
$195.70
contracted rate
Plan paid
$289.30
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-2026-022521 | 2026-08-26 | Pinecrest Primary Care Associates | $515.00 | Needs review |
| CLM-2026-004231 | 2026-04-04 | Unity Medical Group | $436.00 | 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.