CLM-2026-020492
Pinecrest Diagnostic Imaging, Radiology. Service 2026-05-02 at outpatient hospital (POS 22). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Stephanie Chavez
- Member ID
- UHC-88000-54
- Date of birth
- 1946-04-09
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-412971
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8280
- Coverage period
- 2023-12-01 to present
- Deductible
- $55.74 of $500.0011%
- Out-of-pocket maximum
- $377.47 of $1,000.0038%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 6 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
- 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $473.00 | $260.15 | — | — | DeniedCO197 |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,295.00 | $1,262.25 | — | — | DeniedCO197 |
| Totals | $2,768.00 | $1,522.40 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-449602
- 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-034887 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-02: NULL (PPO), effective 2023-12-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 70553 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| 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 Imaging2026-05-02 09:52
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-14 03:42
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-449602.pdf9 pages
Itemised statement totalling $2768.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 70553 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027218 | 2026-07-13 | Desert Internal Medicine Associates | $104.00 | Approved |
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
Precertification required and absent.