Professional claim · CMS-1500 · Provider portal
CLM-2026-027965
Pinecrest Medical Group, Internal Medicine. Service 2025-12-09 at office (POS 11). Received 2026-01-21.
Approved
Billed
$353.00
2 lines
Allowed
$218.86
contract rate applied
Plan pays
$178.86
approved
Member owes
$40.00
copay / deductible / 30% coinsurance
Rules engine
Clean
no reason codes
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Bryan Carter
- Member ID
- UHC-77574-52
- Date of birth
- 1973-11-26
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407084
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0892
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,381.03 of $2,500.0055%
- Out-of-pocket maximum
- $3,649.08 of $7,500.0049%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 1965747839
- 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 | 93000 | Electrocardiogram with interpretation | — | 1 | 1 | $70.00 | $43.40 | $40.00 | $3.40 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 2 | $283.00 | $175.46 | $0.00 | $175.46 | Paid |
| Totals | $353.00 | $218.86 | $40.00 | $178.86 | ||||||
Diagnoses (ICD-10-CM)
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
Claim header
- Patient account
- PA-938821
- 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-006338 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-09: N/A (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 43 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 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Clean claim: approved and priced automatically.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2025-12-09 13:22
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
No attachments.
Explanation of benefits
What the member will see
Amount billed
$353.00
Plan discount
$134.14
contracted rate
Plan paid
$178.86
You may owe
$40.00
copay, deductible and coinsurance
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-2026-002103 | 2026-04-19 | Sunrise Skin Care Associates | $198.00 | Approved |
| CLM-2026-032778 | 2026-02-01 | Lakeside Bone and Joint Center | $269.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Clean claim: the rules engine approved it, so no AI review was needed.
Examiner decision
Approved by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Approvedscenario: Clean
Clean claim, priced at contract rate.