CLM-2026-003405
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-28.
Member
Resolved through the identity graph
- Member
- Cynthia Torres
- Member ID
- UHC-94028-02
- Date of birth
- 1978-03-02
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-406524
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0738
- Coverage period
- 2021-08-01 to present
- Deductible
- $316.01 of $2,500.0013%
- Out-of-pocket maximum
- $3,010.19 of $7,500.0040%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 2908733431
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $597.00 | $328.35 | $328.35 | $0.00 | Paid |
| Totals | $597.00 | $328.35 | $328.35 | $0.00 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-872935
- 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-010790 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-06: SELECT-EPO (EPO), effective 2021-08-01. | |
| Timely filing | Pass | Received 22 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 Associates2026-06-06 18:25
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-872935.pdf6 pages
Itemised statement totalling $597.00 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
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.