CLM-2026-002843
Pinecrest Heart Institute, Cardiology. Service 2026-06-13 at office (POS 11). Received 2026-07-22.
Member
Resolved through the identity graph
- Member
- Elijah Gilbert
- Member ID
- UHC-00785-53
- Date of birth
- 1998-08-12
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-427951
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4048
- Coverage period
- 2021-09-01 to 2026-04-27
- Deductible
- $1,905.39 of $2,500.0076%
- Out-of-pocket maximum
- $1,274.75 of $7,500.0017%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 5431865422
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $309.00 | $191.58 | — | — | DeniedCO27 |
| 2 | 93224 | Holter monitor, 48 hours | — | 1 | 2 | $284.00 | $176.08 | — | — | DeniedCO27 |
| Totals | $593.00 | $367.66 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-706777
- 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-039217 (verified, link confidence 1.00). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-13 is after coverage terminated on 2026-04-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 39 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 Institute2026-06-13 17:12
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-22 06:14
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-22 10:54
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-13 is after coverage terminated on 2026-04-27.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005610 | 2026-07-24 | Desert Family Practice | $60.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.