CLM-2026-017094
Pinecrest Diagnostic Imaging, Radiology. Service 2026-05-26 at outpatient hospital (POS 22). Received 2026-06-15.
Member
Resolved through the identity graph
- Member
- Roger Payne
- Member ID
- UHC-87094-74
- Date of birth
- 2005-04-06
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404664
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-9634
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,077.06 of $1,500.0072%
- Out-of-pocket maximum
- $1,717.48 of $6,000.0029%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7668595177
- Network
- In network
- Rendering NPI
- 4466693437 (Heritage Imaging Center)
- Location
- Tempe, AZ · TIN 35-1293879
- Authorisation / referral
- none / REF606645
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 | $228.00 | $125.40 | — | — | Review |
| Totals | $228.00 | $125.40 | — | — | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-788907
- 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-009479 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-26: CORE-HMO (HMO), effective 2025-01-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-017093, billed by a different provider. Possible duplicate |
| 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 Imaging2026-05-26 14:52
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-06-15 00:41
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Itemized billitemized_PA-788907.pdf2 pages
Itemised statement totalling $228.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-017093, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017093 | 2026-05-26 | Heritage Imaging Center | $228.00 | Approved |
| CLM-2026-007117 | 2026-01-10 | Lakeside Reference Lab | $68.00 | Approved |
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
Different billing provider; separately payable.