CLM-2026-010990
Pinecrest Diagnostic Imaging, Radiology. Service 2026-06-14 at outpatient hospital (POS 22). Received 2026-06-20.
Member
Resolved through the identity graph
- Member
- Jerry Armstrong
- Member ID
- UHC-40480-51
- Date of birth
- 1940-04-10
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-415215
- Relationship
- Child, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4322
- Coverage period
- 2025-07-01 to present
- Deductible
- $883.59 of $2,500.0035%
- Out-of-pocket maximum
- $728.96 of $5,000.0015%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 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
- PA2026277346 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,577.00 | $1,417.35 | — | — | Review |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $148.00 | $81.40 | — | — | Review |
| Totals | $2,725.00 | $1,498.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R51.9 Headache, unspecified
- Patient account
- PA-319792
- 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-004210 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-14: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026277346 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (7668595177). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; 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 Imaging2026-06-14 12:47
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-06-20 02:38
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-06-20 13:35
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026277346_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-14 to 2026-09-12.
- Itemized billitemized_PA-319792.pdf8 pages
Itemised statement totalling $2725.00 across 2 lines.
- Medical recordrecords_PA-319792.pdf6 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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
Notes document medical necessity.