Professional claim · CMS-1500 · EDI 837P
CLM-2026-033439
Pinecrest Medical Group, Family Medicine. Service 2026-08-09 at office (POS 11). Received 2026-08-29.
Denied
Billed
$555.00
3 lines
Allowed
$344.10
if approved
Plan pays
—
Denied
Member owes
—
copay / deductible / 20% coinsurance
Rules engine
Deny
CO27
Decided by
Claims rules engine
2026-10-22 12:44
Member
Resolved through the identity graph
- Member
- Gabriel Perkins
- Member ID
- UHC-10345-15
- Date of birth
- 1979-01-25
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-417043
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6992
- Coverage period
- 2024-08-01 to 2026-02-28
- Deductible
- $46.29 of $2,500.002%
- Out-of-pocket maximum
- $3,590.73 of $7,500.0048%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5469942648
- Network
- In network
- Rendering NPI
- 4799017619
- Location
- Austin, TX · TIN 84-7440514
- 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 | 99203 | Office visit, new patient, low complexity | — | 1 | 1 | $195.00 | $120.90 | — | — | DeniedCO27 |
| 2 | 90471 | Immunization administration | — | 1 | 1,2 | $35.00 | $21.70 | — | — | DeniedCO27 |
| 3 | 99395 | Preventive visit, 18-39 years | — | 1 | 1,2 | $325.00 | $201.50 | — | — | DeniedCO27 |
| Totals | $555.00 | $344.10 | — | — | ||||||
Diagnoses (ICD-10-CM)
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
Claim header
- Patient account
- PA-909992
- 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-028926 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-09 is after coverage terminated on 2026-02-28. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 20 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 (5469942648). | |
| 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. |
Evaluated 2026-10-22 12:44 under policy version 1. Hard rule fired: Denied.
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Medical Group2026-08-09 10:47
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-08-29 04:32
Attachments
Documents received with the claim
No attachments.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-09 is after coverage terminated on 2026-02-28.
Other claims for this member
Same resolved identity
No other claims.
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
A hard rule decided this claim; the AI is advisory here.
Examiner decision
Denied by Claims rules engine; an examiner may still override
Outcome
At least 8 characters (0/8)
ExaminerR. Patel (Claims Examiner II)
Choose an outcome
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
DeniedCO27scenario: Coverage terminated
Service after coverage termination.