CLM-2026-032469
Pinecrest Medical Group, Internal Medicine. Service 2025-11-25 at office (POS 11). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Henry Lane
- Member ID
- UHC-78055-45
- Date of birth
- 1940-09-11
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400585
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4035
- Coverage period
- 2022-09-01 to present
- Deductible
- $1,810.02 of $2,500.0072%
- Out-of-pocket maximum
- $2,269.82 of $5,000.0045%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3001804152
- Network
- In network
- Rendering NPI
- 3763919230
- Location
- Dallas, TX · TIN 55-8186699
- Authorisation / referral
- none / REF895506
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 | 80053 | Comprehensive metabolic panel | — | 1 | 1 | $85.00 | $52.70 | $30.00 | $22.70 | Paid |
| 2 | 99215 | Office visit, established patient, high complexity | — | 1 | 1,2 | $308.00 | $190.96 | $0.00 | $190.96 | Paid |
| Totals | $393.00 | $243.66 | $30.00 | $213.66 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-938835
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-002264 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-25: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 44 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 (3001804152). | |
| 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 Group2025-11-25 14:51
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009132 | 2026-05-13 | Mesa Family Practice | $231.00 | Approved |
| CLM-2026-027133 | 2026-01-09 | Valley Clinical Laboratories | $41.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.