CLM-2026-017923
Pinecrest Diagnostic Imaging, Radiology. Service 2026-02-13 at outpatient hospital (POS 22). Received 2026-02-24.
Member
Resolved through the identity graph
- Member
- Theresa Hudson
- Member ID
- UHC-74120-88
- Date of birth
- 1960-01-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-414418
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-0280
- Coverage period
- 2023-12-01 to present
- Deductible
- $839.79 of $1,000.0084%
- Out-of-pocket maximum
- $556.31 of $2,000.0028%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8391485629
- Network
- In network
- Rendering NPI
- 8391485629
- Location
- Scottsdale, AZ · TIN 15-2373170
- Authorisation / referral
- PA2026366596 / 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 | $1,983.00 | $1,090.65 | $439.34 | $651.31 | Paid |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $110.00 | $60.50 | $18.15 | $42.35 | Paid |
| 3 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1,2 | $1,828.00 | $1,005.40 | $301.62 | $703.78 | Paid |
| Totals | $3,921.00 | $2,156.55 | $759.11 | $1,397.44 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-308802
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015503 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-02-13: MEDICARE-ADV-B (MA), effective 2023-12-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026366596 on file for 74177, 70553. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (8391485629). | |
| 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 Imaging2026-02-13 15:57
Established patient presents with pain in right knee; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026366596_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-02-13 to 2026-05-14.
- Itemized billitemized_PA-308802.pdf3 pages
Itemised statement totalling $3921.00 across 3 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-008116 | 2026-09-05 | Mesa Reference Lab | $108.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.