CLM-2026-033342
Pinecrest Medical Group, Internal Medicine. Service 2025-12-14 to 2025-12-16 at inpatient hospital (POS 21). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Laura Franklin
- Member ID
- UHC-32182-41
- Date of birth
- 1946-02-10
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-429168
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-8263
- Coverage period
- 2025-09-01 to present
- Deductible
- $181.85 of $500.0036%
- Out-of-pocket maximum
- $220.46 of $2,000.0011%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 8331715671
- Network
- In network
- Rendering NPI
- 7591736732
- Location
- Minneapolis, MN · TIN 79-7771425
- Authorisation / referral
- none / none
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 | $237.00 | $130.35 | $130.35 | $0.00 | Paid |
| Totals | $237.00 | $130.35 | $130.35 | $0.00 | ||||||
- 1. E11.65 Type 2 diabetes mellitus with hyperglycemiaprincipal
- Patient account
- PA-129587
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2025-12-14 to 2025-12-15
- 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-002667 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-A (MA), effective 2025-09-01. | |
| Timely filing | Pass | Received 35 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 (8331715671). | |
| 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 Group2025-12-16 09:08
Patient seen for type 2 diabetes mellitus with hyperglycemia.
Attachments
Documents received with the claim
- Itemized billitemized_PA-129587.pdf8 pages
Itemised statement totalling $237.00 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-2026-018848 | 2026-06-15 | Mesa Medical Group | $2,851.00 | Needs review |
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.