CLM-2026-031767
Pinecrest Medical Group, Family Medicine. Service 2026-09-23 at office (POS 11). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Lawrence Young
- Member ID
- UHC-86523-36
- Date of birth
- 1953-09-03
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401833
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8360
- Coverage period
- 2024-03-01 to present
- Deductible
- $652.00 of $1,000.0065%
- Out-of-pocket maximum
- $986.80 of $3,000.0033%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7440098508
- Network
- In network
- Rendering NPI
- 2107875819
- Location
- Miami, FL · TIN 12-0288184
- 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 | 99395 | Preventive visit, 18-39 years | 59 | 1 | 1 | $302.00 | $187.24 | — | — | Review |
| 2 | 99213 | Office visit, established patient, low complexity | 59 | 1 | 1 | $200.00 | $124.00 | — | — | Review |
| Totals | $502.00 | $311.24 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-870468
- 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-012263 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-23: MEDICARE-ADV-A (MA), effective 2024-03-01. | |
| Timely filing | Pass | Received 19 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 (7440098508). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Group2026-09-23 10:19
Follow-up for essential (primary) hypertension. Plan discussed, medications reconciled. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
- SystemSystem: Claims system2026-10-12 03:07
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Medical recordrecords_PA-870468.pdf12 pages
Operative note describing procedures at two distinct anatomical sites.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Modifier 59 supported: distinct anatomical site documented.