CLM-2026-021681
Pinecrest Diagnostic Imaging, Radiology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-02-16.
Member
Resolved through the identity graph
- Member
- Katherine Gonzalez
- Member ID
- none on golden record
- Date of birth
- —
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-430842
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Eligibility
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
- PA2026329224 / REF141914
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 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $262.00 | $144.10 | — | — | PendedIDQ |
| 2 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,273.00 | $1,250.15 | — | — | PendedIDQ |
| 3 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1,2 | $145.00 | $79.75 | — | — | PendedIDQ |
| Totals | $2,680.00 | $1,474.00 | — | — | ||||||
- 1. Z12.31 Encounter for screening mammogram for malignant neoplasm of breastprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R51.9 Headache, unspecified
- Patient account
- PA-370501
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001063; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026329224 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Diagnostic Imaging (7668595177). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity. Not medically necessary per payer policy |
| 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 Imaging2026-01-02 11:14
Patient seen for encounter for screening mammogram for malignant neoplasm of breast.
Attachments
Documents received with the claim
- Prior auth letterPA2026329224_approval.pdf2 pages
Utilisation management approval letter for 77067 (Screening mammography, bilateral), valid 2026-01-02 to 2026-04-02.
- Itemized billitemized_PA-370501.pdf4 pages
Itemised statement totalling $2680.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001063; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. Medical necessity: 70553 billed with routine diagnosis Z12.31; clinical notes must support necessity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.