CLM-2026-032714
Pinecrest Internal Medicine Associates, Internal Medicine. Service 2025-06-28 at office (POS 11). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Michael Kelly
- Member ID
- UHC-55894-77
- Date of birth
- 1984-04-04
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403499
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6451
- Coverage period
- 2024-02-01 to present
- Deductible
- $737.56 of $1,000.0074%
- Out-of-pocket maximum
- $1,077.56 of $4,000.0027%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 9530324190
- Network
- In network
- Rendering NPI
- 6187297190
- Location
- Charlotte, NC · TIN 19-6063238
- 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 | 99215 | Office visit, established patient, high complexity | — | 1 | 1 | $284.00 | $176.08 | — | — | DeniedCO29 |
| Totals | $284.00 | $176.08 | — | — | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-873508
- 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-007407 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-06-28: CHOICE-PLUS-PPO (PPO), effective 2024-02-01. | |
| Timely filing | Fail | CO29 | Received 211 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Associates2025-06-28 10:13
Established patient presents with type 2 diabetes mellitus with hyperglycemia; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-01-25 05:19
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-25 15:49
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 211 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.