CLM-2026-031973
Pinecrest Medical Group, Internal Medicine. Service 2026-08-30 to 2026-09-03 at inpatient hospital (POS 21). Received 2026-10-06.
Member
Resolved through the identity graph
- Member
- Jean Lawrence
- Member ID
- UHC-43612-23
- Date of birth
- 1974-03-03
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423182
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8402
- Coverage period
- 2024-02-01 to 2026-03-07
- Deductible
- $438.63 of $1,500.0029%
- Out-of-pocket maximum
- $66.29 of $3,000.002%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 2287397261
- Location
- Nashville, TN · TIN 22-5526630
- Authorisation / referral
- none / none
Service lines
UB-04: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99232 rev 0110 | Subsequent hospital care | — | 1 | 1 | $161.00 | $88.55 | — | — | DeniedCO27 |
| Totals | $161.00 | $88.55 | — | — | ||||||
- 1. J44.9 COPD, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-360859
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-08-30 to 2026-09-03
- 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-008878 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-30 is after coverage terminated on 2026-03-07. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 (3917182149). | |
| 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 Group2026-09-03 09:05
Patient seen for copd, unspecified.
- SystemSystem: Claims system2026-10-06 02:44
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-06 15:06
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-360859.pdf5 pages
Itemised statement totalling $161.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-08-30 is after coverage terminated on 2026-03-07.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020016 | 2026-03-20 | Mesa Family Practice | $44.00 | 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.