Claims workbench/CLM-2026-022521

Professional claim · CMS-1500 · EDI 837P

CLM-2026-022521

Pinecrest Primary Care Associates, Family Medicine. Service 2026-08-26 at office (POS 11). Received 2026-09-25.

Needs reviewReplacement of CLM-2026-022520

Billed

$515.00

2 lines

Allowed

$319.30

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 30% coinsurance

Rules engine

Review

REPL

Decided by

Nobody yet

open

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 Associates
Family 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	—	—	Review
2	99213	Office visit, established patient, low complexity	—	1	1	$178.00	$110.36	—	—	Review
Totals						$515.00	$319.30	—	—

Diagnoses (ICD-10-CM)

1. I10 Essential (primary) hypertensionprincipal
2. E11.9 Type 2 diabetes mellitus without complications

Claim header

Patient account: PA-593842
Frequency code: 7 (replacement)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 12 checks, 1 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 30 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Replacement claim	Review	REPL	Frequency code 7 replaces CLM-2026-022520; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission
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. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Primary Care Associates2026-08-26 10:23
Patient seen for essential (primary) hypertension. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
SystemSystem: Claims system2026-09-25 03:24
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.

Attachments

Documents received with the claim

Corrected claimcorrected_CLM-2026-022520.pdf1 page
Provider cover letter requesting replacement of CLM-2026-022520.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Replacement claim: Frequency code 7 replaces CLM-2026-022520; the original must be voided when this adjudicates.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022520	2026-08-26	Pinecrest Primary Care Associates	$515.00	Approved
CLM-2026-004231	2026-04-04	Unity Medical Group	$436.00	Approved

AI recommendation

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

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

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

Approvedscenario: Replacement

Replacement claim supersedes the original.

Review queue Member identity