CLM-2026-016090
Pinecrest Diagnostic Imaging, Radiology. Service 2026-05-07 at outpatient hospital (POS 22). Received 2026-05-31.
Member
Resolved through the identity graph
- Member
- Aisha Snyder
- Member ID
- UHC-55261-40
- Date of birth
- 1967-03-11
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-418682
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-2223
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,071.60 of $1,500.0071%
- Out-of-pocket maximum
- $1,832.97 of $4,500.0041%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 10 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
- PA2026712512 / 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 | $1,207.00 | $663.85 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $365.00 | $200.75 | — | — | Review |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $129.00 | $70.95 | — | — | Review |
| Totals | $1,701.00 | $935.55 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-910465
- 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-000597 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2026-05-07: CHOICE-PLUS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026712512 on file for 74177. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (7668595177). | |
| Medical necessity | Review | CO50 | 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Imaging2026-05-07 17:32
Follow-up for encounter for screening mammogram for malignant neoplasm of breast. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026712512_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-07 to 2026-08-05.
- Itemized billitemized_PA-910465.pdf7 pages
Itemised statement totalling $1701.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 74177 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.