CLM-2026-003999
Pinecrest Diagnostic Imaging, Radiology. Service 2025-12-06 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Diane West
- Member ID
- UHC-87387-07
- Date of birth
- 1996-07-02
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413692
- Relationship
- Spouse, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4511
- Coverage period
- 2023-03-01 to present
- Deductible
- $268.98 of $1,000.0027%
- Out-of-pocket maximum
- $802.30 of $3,000.0027%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8391485629
- Network
- In network
- Rendering NPI
- 8391485629
- Location
- Scottsdale, AZ · TIN 15-2373170
- Authorisation / referral
- PA2025035728 / 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $571.00 | $314.05 | — | — | Review |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,285.00 | $1,256.75 | — | — | Review |
| Totals | $2,856.00 | $1,570.80 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- Patient account
- PA-831293
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000161 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-06: MEDICARE-ADV-A (MA), effective 2023-03-01. | |
| Timely filing | Pass | Received 26 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025035728 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (8391485629). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; 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 Diagnostic Imaging2025-12-06 16:47
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025035728_approval.pdf2 pages
Utilisation management approval letter for 76700 (Ultrasound abdomen, complete), valid 2025-12-06 to 2026-03-06.
- Itemized billitemized_PA-831293.pdf5 pages
Itemised statement totalling $2856.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
- AI recommendationPended2026-10-22 12:49The claim has been flagged for medical necessity (CO50) due to the MRI brain with and without contrast (70553) being billed with a routine diagnosis (Z12.31). The clinical notes must support the necessity of this service. The examiner should verify if the clinical notes provide sufficient justification for the MRI.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · 5f208be0
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:49 · c4fa7d85
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-021942 | 2026-03-12 | Pinecrest Diagnostic Imaging | $1,562.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim has been flagged for medical necessity (CO50) due to the MRI brain with and without contrast (70553) being billed with a routine diagnosis (Z12.31). The clinical notes must support the necessity of this service. The examiner should verify if the clinical notes provide sufficient justification for the MRI.
- Verify if the clinical notes support the medical necessity of the MRI brain with and without contrast (70553) for the diagnosis Z12.31.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.