CLM-2026-026906
Pinecrest Medical Group, Internal Medicine. Service 2026-01-03 at office (POS 11). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Kyle Clark
- Member ID
- UHC-08782-72
- Date of birth
- 1986-02-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415951
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group N/A
- Coverage period
- 2023-09-01 to present
- Deductible
- $732.73 of $2,500.0029%
- Out-of-pocket maximum
- $3,292.20 of $10,000.0033%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 4197881103
- Location
- Minneapolis, MN · TIN 79-7771425
- 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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $74.00 | $45.88 | — | — | Review |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $353.00 | $218.86 | — | — | Review |
| Totals | $427.00 | $264.74 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- Patient account
- PA-440329
- Frequency code
- 7 (replacement)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 12 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-003145 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-03: CHOICE-PLUS-PPO (PPO), effective 2023-09-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Replacement claim | Review | REPL | Frequency code 7 replaces CLM-2026-026905; the original must be voided when this adjudicates. Replacement claim; supersedes the original submission |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Medical Group (8331715671). | |
| 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 Group2026-01-03 11:43
Follow-up for copd, unspecified. Plan discussed, medications reconciled. Corrected claim: units on line 2 were keyed incorrectly on the original submission. This claim replaces it in full.
- SystemSystem: Claims system2026-01-20 02:44
Frequency code 7 (replacement) referencing an earlier claim. Original must be voided when this adjudicates.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-20 10:42
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Corrected claimcorrected_CLM-2026-026905.pdf1 page
Provider cover letter requesting replacement of CLM-2026-026905.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Replacement claim: Frequency code 7 replaces CLM-2026-026905; the original must be voided when this adjudicates.
- AI recommendationApproved2026-10-23 19:19This is a replacement claim (frequency code 7) that corrects an earlier submission [N1]. The original claim CLM-2026-026905 has been approved and must be voided [N2]. The provider has submitted a cover letter requesting the replacement [A1]. All other adjudication checks have passed, and the claim is within the auto-adjudication ceiling [R-high_dollar]. The member's identity and coverage are confirmed [R-identity, R-eligibility], and the claim is timely filed [R-timely_filing]. The provider is in-network [R-network], and the medical necessity is supported by the diagnosis [R-clinical_edit].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:19 · 6d03ae5f
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026905 | 2026-01-03 | Pinecrest Medical Group | $427.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
This is a replacement claim (frequency code 7) that corrects an earlier submission [N1]. The original claim CLM-2026-026905 has been approved and must be voided [N2]. The provider has submitted a cover letter requesting the replacement [A1]. All other adjudication checks have passed, and the claim is within the auto-adjudication ceiling [R-high_dollar]. The member's identity and coverage are confirmed [R-identity, R-eligibility], and the claim is timely filed [R-timely_filing]. The provider is in-network [R-network], and the medical necessity is supported by the diagnosis [R-clinical_edit].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Replacement claim supersedes the original.