Claims workbench/CLM-2026-032433

Professional claim · CMS-1500 · EDI 837P

CLM-2026-032433

Pinecrest Behavioral Health, Behavioral Health. Service 2025-12-22 at office (POS 11). Received 2026-01-17.

Denied

Billed

$412.00

1 line

Allowed

$255.44

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO18

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Sarah Nguyen
Member ID: UHC-67677-60
Date of birth: 2004-01-18
Identity: Verified7 records, confidence 0.96
Claim record: CLMCLM-411837
Relationship: Child, Orlando, FL

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-8645
Coverage period: 2021-03-01 to 2026-05-14
Deductible: $909.85 of $1,500.0061%
Out-of-pocket maximum: $1,028.26 of $4,500.0023%
Copays: office $40.00, specialist $40.00, emergency $150.00
Physical therapy visits: 12 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Behavioral Health
Behavioral Health · taxonomy 103T00000X
NPI: 2968932766
Network: In network
Rendering NPI: 6372390917
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	90791	Psychiatric diagnostic evaluation	—	1	1	$412.00	$255.44	—	—	DeniedCO18
Totals						$412.00	$255.44	—	—

Diagnoses (ICD-10-CM)

1. F41.1 Generalized anxiety disorderprincipal

Claim header

Patient account: PA-610393
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-003899 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2025-12-22: MEDICARE-ADV-A (MA), effective 2021-03-01, terms 2026-05-14.
Timely filing	Pass		Received 26 days after service (limit 90).
Duplicate check	Fail	CO18	Exact duplicate of CLM-2026-032432: 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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Behavioral Health2025-12-22 12:33
Follow-up for generalized anxiety disorder. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-01-17 05:34
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-17 13:41
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

No attachments.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Duplicate check: Exact duplicate of CLM-2026-032432: same member, date of service, procedures and billing provider.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-020067	2026-07-31	Pinecrest Cardiovascular Associates	$7,721.00	Denied
CLM-2026-019671	2026-06-30	Unity Primary Care Associates	$311.00	Denied
CLM-2026-021304	2026-06-07	Heritage Family Practice	$336.00	Denied
CLM-2026-034635	2026-04-18	Northgate Heart Institute	$269.00	Approved
CLM-2026-019902	2026-04-05	Meadow Primary Care Associates	$249.00	Approved
CLM-2026-032432	2025-12-22	Pinecrest Behavioral Health	$412.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO18scenario: Duplicate

Exact duplicate of an earlier submission.

Review queue Member identity