CLM-2026-025633
Pinecrest Medical Group, Internal Medicine. Service 2026-03-02 to 2026-03-03 at inpatient hospital (POS 21). Received 2026-06-23.
Member
Resolved through the identity graph
- Member
- Albert Diaz
- Member ID
- UHC-94730-52
- Date of birth
- 1944-07-06
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-421982
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4239
- Coverage period
- 2022-02-01 to 2026-04-19
- Deductible
- $2,146.63 of $2,500.0086%
- Out-of-pocket maximum
- $2,759.77 of $10,000.0028%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3001804152
- Network
- In network
- Rendering NPI
- 2098844519
- Location
- Dallas, TX · TIN 55-8186699
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $196.00 | $107.80 | — | — | DeniedCO29 |
| Totals | $196.00 | $107.80 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-275612
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-02 to 2026-03-03
- 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-010160 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-02: MEDICARE-ADV-B (MA), effective 2022-02-01, terms 2026-04-19. | |
| Timely filing | Fail | CO29 | Received 112 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3001804152). | |
| 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 Group2026-03-03 14:03
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-06-23 03:58
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
- Itemized billitemized_PA-275612.pdf5 pages
Itemised statement totalling $196.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.