CLM-2026-023800
Pinecrest Medical Group, Family Medicine. Service 2025-12-18 at office (POS 11). Received 2026-01-12.
Member
Resolved through the identity graph
- Member
- Frank Lawrence
- Member ID
- UHC-55442-75
- Date of birth
- 1945-09-08
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-428510
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5867
- Coverage period
- 2025-03-01 to present
- Deductible
- $271.58 of $500.0054%
- Out-of-pocket maximum
- $236.57 of $1,500.0016%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 4620916419
- Location
- Austin, TX · TIN 84-7440514
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $191.00 | $118.42 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | — | 1 | 2 | $209.00 | $129.58 | — | — | Review |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 2 | $264.00 | $163.68 | — | — | Review |
| Totals | $664.00 | $411.68 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-139369
- 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-001924 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-12-18: - (PPO), effective 2025-03-01. | |
| Timely filing | Pass | Received 25 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 Medical Group (5469942648). | |
| 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: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”. 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 Medical Group2025-12-18 18:40
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-01-12 06:46
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with type 2 diabetes mellitus without complications; symptoms”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034473 | 2026-03-12 | Sunrise Diagnostic Imaging | $213.00 | Approved |
| CLM-2026-029941 | 2025-12-23 | Mesa Dermatology Clinic | $277.00 | Approved |
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.