CLM-2026-012298
Pinecrest Heart Institute, Cardiology. Service 2026-03-14 at outpatient hospital (POS 22). Received 2026-04-27.
Member
Resolved through the identity graph
- Member
- Janet Hamilton
- Member ID
- UHC-48718-74
- Date of birth
- 1985-07-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415638
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7539
- Coverage period
- 2023-10-01 to 2026-07-08
- Deductible
- $307.40 of $1,500.0020%
- Out-of-pocket maximum
- $330.43 of $3,000.0011%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 6056608980
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- none / REF842332
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $534.00 | $293.70 | $293.70 | $0.00 | Paid |
| Totals | $534.00 | $293.70 | $293.70 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-695196
- 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-028065 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-14: NAVIGATE-HMO (HMO), effective 2023-10-01, terms 2026-07-08. | |
| Timely filing | Pass | Received 44 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 Heart Institute (8218526324). | |
| 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 Heart Institute2026-03-14 12:34
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-695196.pdf8 pages
Itemised statement totalling $534.00 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-2026-029327 | 2026-05-16 | Summit Reference Lab | $191.00 | 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.