CLM-2026-010240
Pinecrest Diagnostic Imaging, Radiology. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Susan Bradley
- Member ID
- UHC-02823-72
- Date of birth
- 1940-04-18
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-419896
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4025
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,520.69 of $2,500.0061%
- Out-of-pocket maximum
- $2,826.86 of $7,500.0038%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 21 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
- PA2025729237 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,045.00 | $1,124.75 | — | — | Review |
| Totals | $2,045.00 | $1,124.75 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R51.9 Headache, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-964344
- 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-003031 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-19: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025729237 on file for 74177. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (8391485629). | |
| Medical necessity | Review | CO50 | 74177 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 Imaging2025-12-19 09:16
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2025729237_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2025-12-19 to 2026-03-19.
- Itemized billitemized_PA-964344.pdf9 pages
Itemised statement totalling $2045.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:42 · 7cf1df31
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029495 | 2026-06-15 | Unity Community Hospital | $976.00 | Approved |
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
Clean claim, priced at contract rate.