CLM-2026-021268
Pinecrest Diagnostic Imaging, Radiology. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-07-19.
Member
Resolved through the identity graph
- Member
- Sam Harrison
- Member ID
- UHC-41931-54
- Date of birth
- 1979-07-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-409277
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-3948
- Coverage period
- 2024-09-01 to present
- Deductible
- $547.87 of $1,000.0055%
- Out-of-pocket maximum
- $47.75 of $2,000.002%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 22 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 / REF341842
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 | $630.00 | $346.50 | $346.50 | $0.00 | Paid |
| Totals | $630.00 | $346.50 | $346.50 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-469822
- 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-038973 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-12: NAVIGATE-HMO (HMO), effective 2024-09-01. | |
| Timely filing | Pass | Received 7 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 Imaging2026-07-12 15:15
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-469822.pdf6 pages
Itemised statement totalling $630.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
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.