CLM-2026-027451
Pinecrest Primary Care Associates, Family Medicine. Service 2026-08-24 at office (POS 11). Received 2026-09-05.
Member
Resolved through the identity graph
- Member
- Jack Espinoza
- Member ID
- UHC-29115-37
- Date of birth
- 2001-01-19
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-428892
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4527
- Coverage period
- 2025-10-01 to 2026-06-09
- Deductible
- $286.96 of $500.0057%
- Out-of-pocket maximum
- $385.30 of $2,000.0019%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2725113155
- Network
- In network
- Rendering NPI
- 3784306755
- 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 | $25.00 | $15.50 | — | — | DeniedCO27 |
| Totals | $25.00 | $15.50 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. M54.50 Low back pain, unspecified
- Patient account
- PA-698062
- 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-001204 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-24 is after coverage terminated on 2026-06-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 12 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 Associates2026-08-24 17:43
Established patient presents with type 2 diabetes mellitus without complications; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-05 00:19
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-24 is after coverage terminated on 2026-06-09.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032484 | 2026-06-05 | Summit Reference Lab | $79.00 | Denied |
| CLM-2026-020948 | 2026-05-13 | Meadow Primary Care Associates | $431.00 | Approved |
| CLM-2026-013504 | 2026-01-07 | Sunrise Behavioral Health | $326.00 | 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
Service after coverage termination.