Claims workbench/CLM-2026-025071
Professional claim · CMS-1500 · EDI 837P

CLM-2026-025071

Pinecrest Medical Group, Internal Medicine. Service 2025-10-26 at office (POS 11). Received 2026-03-08.

Denied
Billed
$60.00
1 line
Allowed
$37.20
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO29
Decided by
Claims rules engine
2026-10-22 12:44

Member

Resolved through the identity graph

Member
Alexis Schultz
Member ID
UHC-14389-28
Date of birth
1942-08-23
Identity
Verified3 records, confidence 0.99
Claim record
CLMCLM-406579
Relationship
Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan
CORE-HMO HMO group GRP-6831
Coverage period
2022-06-01 to present
Deductible
$1,924.93 of $3,500.0055%
Out-of-pocket maximum
$4,497.25 of $14,000.0032%
Copays
office $25.00, specialist $60.00, emergency $350.00
Physical therapy visits
0 of 20 used

Provider

Billing and rendering

Billing provider
Pinecrest Medical Group
Internal Medicine · taxonomy 207R00000X
NPI
3917182149
Network
In network
Rendering NPI
4317293940
Location
Nashville, TN · TIN 22-5526630
Authorisation / referral
none / REF794821

Service lines

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

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
180053Comprehensive metabolic panel—11$60.00$37.20——DeniedCO29
Totals$60.00$37.20——
Diagnoses (ICD-10-CM)
  • 1. I48.91 Unspecified atrial fibrillationprincipal
  • 2. I10 Essential (primary) hypertension
  • 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
Claim header
Patient account
PA-705867
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-008581 (verified, link confidence 0.99).
EligibilityPassActive on 2025-10-26: CORE-HMO (HMO), effective 2022-06-01.
Timely filingFailCO29Received 133 days after the last date of service (limit 90).
Time limit for filing has expired
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 Group2025-10-26 10:04

    Patient seen for unspecified atrial fibrillation.

  • SystemSystem: Claims system2026-03-08 05:03

    Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.

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
    Timely filing: Received 133 days after the last date of service (limit 90).

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queueMember identity