CLM-2026-032521
Pinecrest Family Practice, Family Medicine. Service 2026-01-18 at office (POS 11). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Donna Weaver
- Member ID
- UHC-45899-75
- Date of birth
- 1955-03-14
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-415624
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5792
- Coverage period
- 2022-12-01 to present
- Deductible
- $2,818.50 of $3,500.0081%
- Out-of-pocket maximum
- $2,338.55 of $10,500.0022%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9590925530
- Network
- In network
- Rendering NPI
- 5717044833
- Location
- Denver, CO · TIN 80-5640290
- 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 | 90471 | Immunization administration | — | 1 | 1 | $32.00 | $19.84 | — | — | DeniedCO18 |
| Totals | $32.00 | $19.84 | — | — | ||||||
- 1. E11.9 Type 2 diabetes mellitus without complicationsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-315140
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009021 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-18: NAVIGATE-HMO (HMO), effective 2022-12-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-032520: 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 Family Practice (9590925530). | |
| 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 Family Practice2026-01-18 17:50
Patient seen for type 2 diabetes mellitus without complications.
- SystemSystem: Claims system2026-02-16 02:19
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-02-16 15:46
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-032520: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027616 | 2026-03-26 | Northgate Medical Group | $215.00 | Approved |
| CLM-2026-032520 | 2026-01-18 | Pinecrest Family Practice | $32.00 | Approved |
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
Exact duplicate of an earlier submission.