CLM-2026-016831
Pinecrest Cardiovascular Associates, Cardiology. Service 2025-12-02 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Maria Freeman
- Member ID
- UHC-32653-89
- Date of birth
- 2004-03-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-425893
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1360
- Coverage period
- 2021-08-01 to present
- Deductible
- $1,326.62 of $2,500.0053%
- Out-of-pocket maximum
- $1,235.86 of $5,000.0025%
- Copays
- office $40.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 1955098136
- Location
- Houston, TX · TIN 79-8590773
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $543.00 | $298.65 | — | — | DeniedCO18 |
| Totals | $543.00 | $298.65 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-886401
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000706 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-02: MEDICARE-ADV-A (MA), effective 2021-08-01. | |
| Timely filing | Pass | Received 47 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-016830: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Pinecrest Cardiovascular Associates (4926340728). | |
| 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 Cardiovascular Associates2025-12-02 09:33
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-01-18 05:58
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
- Itemized billitemized_PA-886401.pdf4 pages
Itemised statement totalling $543.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Duplicate check: Exact duplicate of CLM-2026-016830: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020988 | 2025-12-22 | Heritage Clinical Laboratories | $169.00 | Approved |
| CLM-2026-016830 | 2025-12-02 | Pinecrest Cardiovascular Associates | $543.00 | Approved |
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
Exact duplicate of an earlier submission.