CLM-2026-017893
Pinecrest Heart Institute, Cardiology. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-07-02.
Member
Resolved through the identity graph
- Member
- Joshua Hayes
- Member ID
- UHC-85275-22
- Date of birth
- 1956-04-13
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-407955
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1321
- Coverage period
- 2023-11-01 to present
- Deductible
- $177.83 of $500.0036%
- Out-of-pocket maximum
- $239.23 of $2,000.0012%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 6030647229
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- PA2026972871 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,646.00 | $1,455.30 | — | — | Review |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,496.00 | $3,022.80 | — | — | Review |
| 3 | 93015 | Cardiovascular stress test | — | 1 | 1 | $377.00 | $207.35 | — | — | Review |
| Totals | $8,519.00 | $4,685.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-489928
- 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-010152 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-16: OPTIONS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026972871 on file for 70553, 93458. | |
| Provider network | Pass | In-network provider Pinecrest Heart Institute (8218526324). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; 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 Heart Institute2026-06-16 18:42
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-07-02 05:20
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026972871_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-16 to 2026-09-14.
- Itemized billitemized_PA-489928.pdf7 pages
Itemised statement totalling $8519.00 across 3 lines.
- Medical recordrecords_PA-489928.pdf5 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; 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
Notes document medical necessity.