CLM-2026-033501
Pinecrest Medical Group, Internal Medicine. Service 2026-07-17 to 2026-07-18 at inpatient hospital (POS 21). Received 2026-08-31.
Member
Resolved through the identity graph
- Member
- Alexander Munoz
- Member ID
- UHC-66286-28
- Date of birth
- 1971-02-14
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-431524
- Relationship
- Child, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group UNKNOWN
- Coverage period
- 2025-07-01 to present
- Deductible
- $117.15 of $500.0023%
- Out-of-pocket maximum
- $102.01 of $1,000.0010%
- Copays
- office $20.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 3917182149
- Network
- In network
- Rendering NPI
- 8182454552
- Location
- Nashville, TN · TIN 22-5526630
- 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 | $183.00 | $100.65 | $100.65 | $0.00 | Paid |
| Totals | $183.00 | $100.65 | $100.65 | $0.00 | ||||||
- 1. N18.30 Chronic kidney disease, stage 3 unspecifiedprincipal
- 2. J44.9 COPD, unspecified
- Patient account
- PA-741940
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- 2026-07-17 to 2026-07-21
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009379 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-17: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 44 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 (3917182149). | |
| 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 Group2026-07-18 17:15
Follow-up for chronic kidney disease, stage 3 unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-741940.pdf9 pages
Itemised statement totalling $183.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.