CLM-2026-013799
Pinecrest Diagnostic Imaging, Radiology. Service 2026-08-30 at outpatient hospital (POS 22). Received 2026-09-13.
Member
Resolved through the identity graph
- Member
- Jacqueline Maldunado
- Member ID
- UHC-66870-46
- Date of birth
- 1998-04-09
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-404891
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9876
- Coverage period
- 2022-06-01 to present
- Deductible
- $1,783.77 of $2,500.0071%
- Out-of-pocket maximum
- $3,543.82 of $7,500.0047%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 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
- none / 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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $290.00 | $159.50 | $159.50 | $0.00 | Paid |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | 25 | 1 | 1,2 | $358.00 | $196.90 | $196.90 | $0.00 | Paid |
| Totals | $648.00 | $356.40 | $356.40 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. M25.561 Pain in right knee
- Patient account
- PA-136112
- 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-044036 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-08-30: MEDICARE-ADV-A (MA), effective 2022-06-01. | |
| Timely filing | Pass | Received 14 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 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 Imaging2026-08-30 18:05
Patient seen for headache, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-136112.pdf6 pages
Itemised statement totalling $648.00 across 2 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.