CLM-2026-001988
Pinecrest Heart Institute, Cardiology. Service 2026-03-01 at outpatient hospital (POS 22). Received 2026-03-09.
Member
Resolved through the identity graph
- Member
- Frances Carpenter
- Member ID
- UHC-94353-46
- Date of birth
- 1989-07-13
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-413349
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group NULL
- Coverage period
- 2025-11-01 to present
- Deductible
- $246.29 of $1,500.0016%
- Out-of-pocket maximum
- $881.51 of $4,500.0020%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 8147429293
- Location
- Mesa, AZ · TIN 32-1379406
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $687.00 | $377.85 | $377.85 | $0.00 | Paid |
| Totals | $687.00 | $377.85 | $377.85 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-377337
- 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-000097 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-01: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 8 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 Heart Institute (8218526324). | |
| 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 Heart Institute2026-03-01 18:26
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-377337.pdf6 pages
Itemised statement totalling $687.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027208 | 2025-08-18 | Unity Dermatology Clinic | $466.00 | 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.