CLM-2026-019176
Pinecrest Diagnostic Imaging, Radiology. Service 2026-03-10 at outpatient hospital (POS 22). Received 2026-04-17.
Member
Resolved through the identity graph
- Member
- Hiroshi Garza
- Member ID
- UHC-77416-36
- Date of birth
- 2005-11-05
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426133
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-5015
- Coverage period
- 2022-09-01 to present
- Deductible
- $98.21 of $500.0020%
- Out-of-pocket maximum
- $345.87 of $1,500.0023%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 15 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
- none / REF959215
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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $495.00 | $272.25 | $272.25 | $0.00 | Paid |
| Totals | $495.00 | $272.25 | $272.25 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-540340
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020757 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-10: NAVIGATE-HMO (HMO), effective 2022-09-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| 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 Imaging2026-03-10 13:46
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-540340.pdf5 pages
Itemised statement totalling $495.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-015063 | 2026-03-13 | Harbor Primary Care Associates | $2,539.00 | Denied |
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.