CLM-2026-005411
Pinecrest Diagnostic Imaging, Radiology. Service 2026-06-11 at outpatient hospital (POS 22). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Donald Lene
- Member ID
- UHC-25028-43
- Date of birth
- 1974-01-25
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-425440
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-9120
- Coverage period
- 2025-09-01 to present
- Deductible
- $5.35 of $500.001%
- Out-of-pocket maximum
- $858.60 of $2,000.0043%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7668595177
- Network
- In network
- Rendering NPI
- 7668595177
- Location
- Tempe, AZ · TIN 35-1293879
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $119.00 | $65.45 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1,2 | $567.00 | $311.85 | — | — | Review |
| Totals | $686.00 | $377.30 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-899725
- 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-033980 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-06-11: CHOICE-PLUS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 20 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 Diagnostic Imaging (7668595177). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Diagnostic Imaging2026-06-11 13:42
Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-07-01 05:47
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-899725.pdf6 pages
Itemised statement totalling $686.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with unspecified abdominal pain; symptoms reviewed and vitals”.
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
Development letter outstanding.