CLM-2026-000159
Pinecrest Diagnostic Imaging, Radiology. Service 2025-11-27 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Eugene Nichols
- Member ID
- UHC-77317-26
- Date of birth
- 1980-03-11
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-424569
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-4279
- Coverage period
- 2023-12-01 to 2026-01-10
- Deductible
- $1,986.40 of $2,500.0079%
- Out-of-pocket maximum
- $330.96 of $7,500.004%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8391485629
- Network
- In network
- Rendering NPI
- 8391485629
- Location
- Scottsdale, AZ · TIN 15-2373170
- Authorisation / referral
- PA2025648084 / REF546968
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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,329.00 | $1,280.95 | $743.81 | $537.14 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1,2 | $395.00 | $217.25 | $65.18 | $152.07 | Paid |
| Totals | $2,724.00 | $1,498.20 | $808.99 | $689.21 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-294071
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-002529 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-11-27: NAVIGATE-HMO (HMO), effective 2023-12-01, terms 2026-01-10. | |
| Timely filing | Pass | Received 42 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025648084 on file for 74177. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (8391485629). | |
| 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 Diagnostic Imaging2025-11-27 17:33
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025648084_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-11-27 to 2026-02-25.
- Itemized billitemized_PA-294071.pdf5 pages
Itemised statement totalling $2724.00 across 2 lines.
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-2026-017962 | 2026-05-20 | Unity Digestive Health Center | $4,722.00 | Denied |
| CLM-2026-004980 | 2026-01-14 | Harbor Clinical Laboratories | $91.00 | Denied |
| CLM-2026-000160 | 2025-11-27 | Pinecrest Diagnostic Imaging | $2,724.00 | 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.