CLM-2026-015021
Pinecrest Heart Institute, Cardiology. Service 2026-04-26 at outpatient hospital (POS 22). Received 2026-05-23.
Member
Resolved through the identity graph
- Member
- Ana Banks
- Member ID
- UHC-34703-52
- Date of birth
- 1968-01-12
- Identity
- Verified6 records, confidence 0.90
- Claim record
- CLMCLM-404328
- Relationship
- Self, Minneapolis, MN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-8002
- Coverage period
- 2023-04-01 to 2026-03-10
- Deductible
- $325.98 of $1,500.0022%
- Out-of-pocket maximum
- $652.66 of $3,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 1252546688
- Location
- Mesa, AZ · TIN 32-1379406
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,353.00 | $744.15 | — | — | DeniedCO27 |
| Totals | $1,353.00 | $744.15 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-310207
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011694 (verified, link confidence 0.90). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-26 is after coverage terminated on 2026-03-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 27 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 Institute2026-04-26 12:54
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-23 00:39
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-23 08:15
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-310207.pdf4 pages
Itemised statement totalling $1353.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-04-26 is after coverage terminated on 2026-03-10.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020365 | 2026-08-27 | Cornerstone Reference Lab | $89.00 | Denied |
| CLM-2026-008318 | 2026-07-18 | Riverside Community Hospital | $2,732.00 | Denied |
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
Service after coverage termination.