CLM-2026-001490
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-05-26 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Brenda Phillips
- Member ID
- UHC-75690-49
- Date of birth
- 1961-06-05
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-429101
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1910
- Coverage period
- 2025-06-01 to present
- Deductible
- $385.92 of $3,500.0011%
- Out-of-pocket maximum
- $3,380.82 of $7,000.0048%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 7386793740
- Location
- Houston, TX · TIN 79-8590773
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,437.00 | $790.35 | $790.35 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $405.00 | $222.75 | $222.75 | $0.00 | Paid |
| Totals | $1,842.00 | $1,013.10 | $1,013.10 | $0.00 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-351555
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- 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-021781 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-05-26: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 17 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 Cardiovascular Associates (4926340728). | |
| 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 Cardiovascular Associates2026-05-26 16:30
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-351555.pdf2 pages
Itemised statement totalling $1842.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031587 | 2026-05-18 | Desert Imaging Center | $229.00 | Approved |
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.