CLM-2026-013440
Pinecrest Diagnostic Imaging, Radiology. Service 2026-04-10 at outpatient hospital (POS 22). Received 2026-05-08.
Member
Resolved through the identity graph
- Member
- Adam Reyes
- Member ID
- UHC-17564-24
- Date of birth
- 2000-06-15
- Identity
- Verified3 records, confidence 0.94
- Claim record
- CLMCLM-417707
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-3899
- Coverage period
- 2022-11-01 to present
- Deductible
- $107.60 of $500.0022%
- Out-of-pocket maximum
- $110.58 of $2,000.006%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 3 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
- PA2026870560 / 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 | $1,457.00 | $801.35 | $474.19 | $327.16 | Paid |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,967.00 | $1,631.85 | $326.37 | $1,305.48 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $510.00 | $280.50 | $56.10 | $224.40 | Paid |
| Totals | $4,934.00 | $2,713.70 | $856.66 | $1,857.04 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-748365
- 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-029694 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2026-04-10: NULL (PPO), effective 2022-11-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026870560 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (7668595177). | |
| 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 Imaging2026-04-10 12:11
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2026870560_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-04-10 to 2026-07-09.
- Itemized billitemized_PA-748365.pdf2 pages
Itemised statement totalling $4934.00 across 3 lines.
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
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.