Claims workbench/CLM-2026-024759
Professional claim · CMS-1500 · Paper

CLM-2026-024759

Pinecrest Medical Group, Internal Medicine. Service 2026-07-06 at office (POS 11). Received 2026-08-19.

Denied
Billed
$94.00
1 line
Allowed
$58.28
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 10% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Alexis Moore
Member ID
UHC-10333-27
Date of birth
1995-12-09
Identity
Verified2 records, confidence 0.99
Claim record
CLMCLM-414778
Relationship
Self, Plano, TX

Coverage and accumulators

Found by member ID

Plan
N/A PPO group NULL
Coverage period
2024-02-01 to 2026-02-19
Deductible
$368.87 of $500.0074%
Out-of-pocket maximum
$388.94 of $1,000.0039%
Copays
office $20.00, specialist $60.00, emergency $150.00
Physical therapy visits
2 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3917182149
Network
In network
Rendering NPI
2970791119
Location
Nashville, TN · TIN 22-5526630
Authorisation / referral
none / none

Service lines

CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193000Electrocardiogram with interpretation—11$94.00$58.28——DeniedCO27
Totals$94.00$58.28——
Diagnoses (ICD-10-CM)
  • 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
Claim header
Patient account
PA-962843
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

CheckResultCodeDetail
Member identityPassAttached to MBR-040587 (verified, link confidence 0.99).
EligibilityFailCO27Date of service 2026-07-06 is after coverage terminated on 2026-02-19.
Expenses incurred after coverage terminated
Timely filingPassReceived 44 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassNo line requires precertification.
Provider networkPassIn-network provider Pinecrest Medical Group (3917182149).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Pinecrest Medical Group2026-07-06 10:05

    Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.

  • SystemSystem: Claims system2026-08-19 02:22

  • AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-19 08:03

    Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules engineDenied2026-10-22 12:44
    Eligibility: Date of service 2026-07-06 is after coverage terminated on 2026-02-19.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied 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

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queueMember identity