CLM-2026-029735
Pinecrest Medical Group, Family Medicine. Service 2026-06-19 at office (POS 11). Received 2026-07-24.
Member
Resolved through the identity graph
- Member
- Shirley Perez
- Member ID
- UHC-31141-31
- Date of birth
- 1954-06-19
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431531
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4282
- Coverage period
- 2024-08-01 to present
- Deductible
- $501.53 of $3,500.0014%
- Out-of-pocket maximum
- $2,408.66 of $7,000.0034%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 2732475423
- Network
- In network
- Rendering NPI
- 9585326694
- Location
- Tempe, AZ · TIN 64-9893800
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $317.00 | $196.54 | $30.00 | $166.54 | Paid |
| 2 | 99203 | Office visit, new patient, low complexity | 25 | 1 | 2 | $206.00 | $127.72 | $0.00 | $127.72 | Paid |
| Totals | $523.00 | $324.26 | $30.00 | $294.26 | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-455749
- 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-010222 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-19: MEDICARE-ADV-B (MA), effective 2024-08-01. | |
| Timely filing | Pass | Received 35 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 (2732475423). | |
| 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 Group2026-06-19 15:59
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 engineApproved2026-10-22 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.