CLM-2026-019390
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-08-15 at outpatient hospital (POS 22). Received 2026-09-19.
Member
Resolved through the identity graph
- Member
- Jeffrey Cruz
- Member ID
- UHC-77455-14
- Date of birth
- 1971-02-10
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415784
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5188
- Coverage period
- 2022-06-01 to 2026-06-08
- Deductible
- $2,183.26 of $2,500.0087%
- Out-of-pocket maximum
- $571.70 of $5,000.0011%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 1576272482
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,288.00 | $708.40 | — | — | DeniedCO27 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $439.00 | $241.45 | — | — | DeniedCO27 |
| Totals | $1,727.00 | $949.85 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-817446
- 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-022618 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-08-15 is after coverage terminated on 2026-06-08. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 35 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 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 Associates2026-08-15 17:14
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-19 02:10
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-19 09:00
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-817446.pdf5 pages
Itemised statement totalling $1727.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-08-15 is after coverage terminated on 2026-06-08.
Other claims for this member
Same resolved identity
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
Service after coverage termination.