CLM-2026-026797
Pinecrest Primary Care Associates, Family Medicine. Service 2026-06-27 at office (POS 11). Received 2026-07-13.
Member
Resolved through the identity graph
- Member
- Peter Castillo
- Member ID
- UHC-85777-05
- Date of birth
- 2007-04-06
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-419523
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2022-02-01 to present
- Deductible
- $298.26 of $500.0060%
- Out-of-pocket maximum
- $42.45 of $1,000.004%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6406754658
- Network
- In network
- Rendering NPI
- 7265501933
- Location
- Tempe, AZ · TIN 31-0675839
- 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 | 36415 | Venipuncture | — | 1 | 1 | $20.00 | $12.40 | $12.40 | $0.00 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $297.00 | $184.14 | $0.00 | $184.14 | Paid |
| Totals | $317.00 | $196.54 | $12.40 | $184.14 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-794068
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000993 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-27: CHOICE-PLUS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 16 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 Primary Care Associates (6406754658). | |
| 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 Primary Care Associates2026-06-27 09:45
Patient seen for type 2 diabetes mellitus without complications.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029719 | 2026-05-26 | Harbor Bone and Joint Center | $180.00 | Approved |
| CLM-2026-022371 | 2025-12-07 | Harbor Physical Therapy | $388.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.