CLM-2026-030878
Pinecrest Behavioral Health, Behavioral Health. Service 2026-06-21 at office (POS 11). Received 2026-07-08.
Member
Resolved through the identity graph
- Member
- Sophia Foster
- Member ID
- none on golden record
- Date of birth
- 1990-08-12
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-422677
- Relationship
- Spouse
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-A MA group GRP-0992
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,766.25 of $2,500.0071%
- Out-of-pocket maximum
- $3,979.71 of $10,000.0040%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 2669026165
- Location
- Nashville, TN · TIN 20-1333588
- 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 | 90837 | Psychotherapy, 60 minutes | — | 1 | 1 | $216.00 | $133.92 | — | — | DeniedCO18 |
| 2 | 90834 | Psychotherapy, 45 minutes | — | 1 | 1 | $163.00 | $101.06 | — | — | DeniedCO18 |
| 3 | 90791 | Psychiatric diagnostic evaluation | — | 1 | 2 | $421.00 | $261.02 | — | — | DeniedCO18 |
| Totals | $800.00 | $496.00 | — | — | ||||||
- 1. F90.2 ADHD, combined typeprincipal
- Patient account
- PA-782028
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002719; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-21: MEDICARE-ADV-A (MA), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-030877: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Behavioral Health (2968932766). | |
| 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 Behavioral Health2026-06-21 14:19
Follow-up for adhd, combined type. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-07-08 00:41
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-08 12:57
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-002719; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-21: MEDICARE-ADV-A (MA), effective 2022-05-01. Coverage found by name and date of birth because the claim carried no usable member ID. Duplicate check: Exact duplicate of CLM-2026-030877: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030877 | 2026-06-21 | Pinecrest Behavioral Health | $800.00 | Pended |
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
Exact duplicate of an earlier submission.