CLM-2026-011120
Pinecrest Diagnostic Imaging, Radiology. Service 2026-02-16 at outpatient hospital (POS 22). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Nicole Banks
- Member ID
- UHC-03903-87
- Date of birth
- 1996-12-26
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-414423
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-5995
- Coverage period
- 2023-08-01 to present
- Deductible
- $78.85 of $2,500.003%
- Out-of-pocket maximum
- $1,192.97 of $7,500.0016%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 2 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
- PA2025269679 / 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 | $1,715.00 | $943.25 | $943.25 | $0.00 | Paid |
| Totals | $1,715.00 | $943.25 | $943.25 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-882597
- 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-020421 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-02-16: NULL (PPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025269679 on file for 74177. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (8391485629). | |
| 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 Diagnostic Imaging2026-02-16 18:14
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025269679_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-16 to 2026-05-17.
- Itemized billitemized_PA-882597.pdf2 pages
Itemised statement totalling $1715.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003673 | 2026-09-01 | Meadow Family Practice | $251.00 | Needs review |
| CLM-2026-003672 | 2026-09-01 | Mesa Medical Group | $251.00 | Approved |
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.