CLM-2026-024692
Pinecrest Medical Group, Family Medicine. Service 2026-08-07 at office (POS 11). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Natalie Hicks
- Member ID
- UHC-73470-12
- Date of birth
- 1986-02-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-402575
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9462
- Coverage period
- 2025-05-01 to 2026-04-15
- Deductible
- $617.66 of $1,000.0062%
- Out-of-pocket maximum
- $1,051.35 of $3,000.0035%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 9847591994
- 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 | 99213 | Office visit, established patient, low complexity | — | 1 | 1 | $184.00 | $114.08 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | — | 1 | 1 | $27.00 | $16.74 | — | — | DeniedCO27 |
| Totals | $211.00 | $130.82 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-291787
- 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-038328 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-07 is after coverage terminated on 2026-04-15. Expenses incurred after coverage terminated |
| 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 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2026-08-07 17:16
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-14 04:41
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-07 is after coverage terminated on 2026-04-15.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025980 | 2026-08-19 | Meadow Physical Therapy | $216.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.