CLM-2026-031884
Pinecrest Behavioral Health, Behavioral Health. Service 2026-08-05 at telehealth (POS 02). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Terry Tran
- Member ID
- UHC-88172-96
- Date of birth
- 1943-01-01
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418574
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8494
- Coverage period
- 2021-11-01 to present
- Deductible
- $483.69 of $1,000.0048%
- Out-of-pocket maximum
- $779.27 of $3,000.0026%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2968932766
- Network
- In network
- Rendering NPI
- 8515785813
- 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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $242.00 | $150.04 | — | — | PendedIDQ |
| Totals | $242.00 | $150.04 | — | — | ||||||
- 1. F43.10 Post-traumatic stress disorder, unspecifiedprincipal
- 2. F41.1 Generalized anxiety disorder
- Patient account
- PA-540429
- 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 | Fail | IDQ | Member record is in open steward case CASE-004285; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-08-05: CHOICE-PLUS-PPO (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 11 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 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 Health2026-08-05 14:37
Follow-up for post-traumatic stress disorder, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004285; payment withheld until the identity is confirmed.
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
Clean claim, priced at contract rate.