CLM-2026-002424
Pinecrest Heart Institute, Cardiology. Service 2026-06-09 at outpatient hospital (POS 22). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Peter Marshall
- Member ID
- UHC-35606-34
- Date of birth
- 1968-10-23
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-432402
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5501
- Coverage period
- 2023-09-01 to present
- Deductible
- $657.69 of $1,500.0044%
- Out-of-pocket maximum
- $1,754.04 of $6,000.0029%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 4659167975
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- PA2025946937 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $1,991.00 | $1,095.05 | — | — | Review |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $459.00 | $252.45 | — | — | Review |
| 3 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $911.00 | $501.05 | — | — | Review |
| Totals | $3,361.00 | $1,848.55 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-888715
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-036642 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-09: MEDICARE-ADV-B (MA), effective 2023-09-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025946937 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Heart Institute (8218526324). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Institute2026-06-09 15:53
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-07-22 06:33
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025946937_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-09 to 2026-09-07.
- Itemized billitemized_PA-888715.pdf2 pages
Itemised statement totalling $3361.00 across 3 lines.
- Medical recordrecords_PA-888715.pdf4 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.