CLM-2026-022884
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2026-02-13 at office (POS 11). Received 2026-03-23.
Member
Resolved through the identity graph
- Member
- Alex Murphy
- Member ID
- UHC-07023-35
- Date of birth
- 1960-08-22
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-400770
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1136
- Coverage period
- 2023-12-01 to present
- Deductible
- $1,550.82 of $2,500.0062%
- Out-of-pocket maximum
- $2,465.64 of $10,000.0025%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9530324190
- Network
- In network
- Rendering NPI
- 3583822291
- Location
- Charlotte, NC · TIN 19-6063238
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $274.00 | $169.88 | — | — | Review |
| Totals | $274.00 | $169.88 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-659224
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001175 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-B (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 38 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 Internal Medicine Associates (9530324190). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Internal Medicine Associates2026-02-13 10:39
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-23 03:28
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-23 16:37
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Not”.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Development letter outstanding.