CLM-2026-025088
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2026-09-02 at office (POS 11). Received 2026-10-18.
Member
Resolved through the identity graph
- Member
- Julie Hart
- Member ID
- UHC-16029-61
- Date of birth
- 1940-08-25
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-426641
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5217
- Coverage period
- 2025-06-01 to present
- Deductible
- $10.40 of $1,000.001%
- Out-of-pocket maximum
- $607.59 of $4,000.0015%
- Copays
- office $25.00, 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
- 6098680237
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $76.00 | $47.12 | — | — | DeniedCO18 |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $234.00 | $145.08 | — | — | DeniedCO18 |
| Totals | $310.00 | $192.20 | — | — | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-900052
- 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-008010 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-02: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 46 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-025087: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 | Pass | Required documentation present. | |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Internal Medicine Associates2026-09-02 17:27
Established patient presents with chronic kidney disease, stage 3 unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-18 00:37
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-18 11:01
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-025087: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-025087 | 2026-09-02 | Pinecrest Internal Medicine Associates | $310.00 | Approved |
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
Exact duplicate of an earlier submission.