CLM-2026-028105
Pinecrest Medical Group, Internal Medicine. Service 2026-04-19 to 2026-04-20 at inpatient hospital (POS 21). Received 2026-06-02.
Member
Resolved through the identity graph
- Member
- Jennifer Padilla
- Member ID
- UHC-67801-38
- Date of birth
- 2000-05-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-413725
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-0200
- Coverage period
- 2021-10-01 to present
- Deductible
- $214.38 of $1,500.0014%
- Out-of-pocket maximum
- $534.85 of $4,500.0012%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 3611419375
- Location
- Nashville, TN · TIN 22-5526630
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $213.00 | $117.15 | $117.15 | $0.00 | Paid |
| Totals | $213.00 | $117.15 | $117.15 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-977267
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-04-19 to 2026-04-20
- 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-008106 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-19: N/A (PPO), effective 2021-10-01. | |
| 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 (3917182149). | |
| 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 Group2026-04-20 16:39
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-977267.pdf9 pages
Itemised statement totalling $213.00 across 1 line.
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
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.