CLM-2026-031707
Pinecrest Primary Care Associates, Family Medicine. Service 2026-02-25 at office (POS 11). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Ahmed Wells
- Member ID
- UHC-76495-59
- Date of birth
- 1988-02-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-410761
- Relationship
- Child, Columbus, OH
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1906
- Coverage period
- 2024-01-01 to 2026-02-11
- Deductible
- $320.91 of $500.0064%
- Out-of-pocket maximum
- $176.71 of $1,000.0018%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2725113155
- Network
- In network
- Rendering NPI
- 9805880694
- 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 | $31.00 | $19.22 | — | — | DeniedCO27 |
| Totals | $31.00 | $19.22 | — | — | ||||||
- 1. M54.50 Low back pain, unspecifiedprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-594381
- 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-016834 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-25 is after coverage terminated on 2026-02-11. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 Associates2026-02-25 14:46
Follow-up for low back pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-02 05:34
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-02 16:46
Called the provider office; awaiting documentation.
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 2026-02-25 is after coverage terminated on 2026-02-11.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026680 | 2026-03-31 | Meadow Clinical Laboratories | $57.00 | Denied |
| CLM-2026-006795 | 2026-03-03 | Northgate Internal Medicine Associates | $367.00 | Denied |
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.