CLM-2026-011964
Pinecrest Diagnostic Imaging, Radiology. Service 2026-07-01 at outpatient hospital (POS 22). Received 2026-07-26.
Member
Resolved through the identity graph
- Member
- Carl Lewis
- Member ID
- UHC-93843-37
- Date of birth
- 1984-10-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412936
- Relationship
- Child, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5372
- Coverage period
- 2022-09-01 to present
- Deductible
- $2,224.99 of $3,500.0064%
- Out-of-pocket maximum
- $1,704.26 of $14,000.0012%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 22 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
- none / REF605983
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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $255.00 | $140.25 | — | — | DeniedCO197 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $327.00 | $179.85 | — | — | DeniedCO197 |
| 3 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,148.00 | $1,181.40 | — | — | DeniedCO197 |
| Totals | $2,730.00 | $1,501.50 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-101473
- 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-039725 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-01: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 74177 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Imaging2026-07-01 14:00
Patient seen for headache, unspecified.
- SystemSystem: Claims system2026-07-26 00:56
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-26 08:32
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-101473.pdf5 pages
Itemised statement totalling $2730.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 74177 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028700 | 2026-07-08 | Sunrise Medical Group | $523.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Precertification required and absent.