CLM-2026-032697
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2026-03-05 to 2026-03-08 at inpatient hospital (POS 21). Received 2026-04-10.
Member
Resolved through the identity graph
- Member
- Camila James
- Member ID
- UHC-60493-89
- Date of birth
- 1990-08-22
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-401717
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8433
- Coverage period
- 2021-06-01 to present
- Deductible
- $416.50 of $1,500.0028%
- Out-of-pocket maximum
- $19.26 of $4,500.000%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9530324190
- Network
- In network
- Rendering NPI
- 8867215484
- Location
- Charlotte, NC · TIN 19-6063238
- Authorisation / referral
- none / REF745294
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 | $194.00 | $106.70 | $106.70 | $0.00 | Paid |
| Totals | $194.00 | $106.70 | $106.70 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- 3. E11.65 Type 2 diabetes mellitus with hyperglycemia
- Patient account
- PA-705516
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-03-05 to 2026-03-09
- 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-005539 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-05: NAVIGATE-HMO (HMO), effective 2021-06-01. | |
| 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 Internal Medicine Associates (9530324190). | |
| 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 Internal Medicine Associates2026-03-08 14:59
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-705516.pdf8 pages
Itemised statement totalling $194.00 across 1 line.
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-2026-000581 | 2026-09-29 | Unity Medical Group | $208.00 | Approved |
| CLM-2026-021324 | 2025-12-20 | Harbor Medical Group | $163.00 | 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.