CLM-2026-027062
Pinecrest Primary Care Associates, Family Medicine. Service 2026-05-19 at office (POS 11). Received 2026-06-29.
Member
Resolved through the identity graph
- Member
- Samuel Guerrero
- Member ID
- UHC-70261-24
- Date of birth
- 2004-08-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-414510
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7957
- Coverage period
- 2024-03-01 to present
- Deductible
- $617.38 of $2,500.0025%
- Out-of-pocket maximum
- $1,159.38 of $5,000.0023%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2725113155
- Network
- In network
- Rendering NPI
- 6241530321
- Location
- Los Angeles, CA · TIN 32-6244181
- 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 | 90471 | Immunization administration | — | 1 | 1 | $36.00 | $22.32 | $20.00 | $2.32 | Paid |
| 2 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 2 | $207.00 | $128.34 | $0.00 | $128.34 | Paid |
| Totals | $243.00 | $150.66 | $20.00 | $130.66 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- Patient account
- PA-500314
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001242 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-19: CORE-HMO (HMO), effective 2024-03-01. | |
| Timely filing | Pass | Received 41 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 (2725113155). | |
| 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 Associates2026-05-19 12:00
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 engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031373 | 2026-09-30 | Canyon Internal Medicine Associates | $73.00 | Denied |
| CLM-2026-032116 | 2026-05-23 | Evergreen Orthopedic Specialists | $50,607.00 | Needs review |
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.