CLM-2026-022790
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-06-18 at outpatient hospital (POS 22). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Donald Vazquez
- Member ID
- UHC-46967-70
- Date of birth
- 1967-07-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420177
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8994
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,145.23 of $1,500.0076%
- Out-of-pocket maximum
- $301.50 of $6,000.005%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 5820992605
- 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 | $1,190.00 | $654.50 | — | — | DeniedCO18 |
| Totals | $1,190.00 | $654.50 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-275881
- 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-024538 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-18: CHOICE-PLUS-PPO (PPO), effective 2025-04-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-022789: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Associates2026-06-18 11:06
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-28 06:45
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-28 17:29
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-275881.pdf3 pages
Itemised statement totalling $1190.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-022789: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022789 | 2026-06-18 | Pinecrest Cardiovascular Associates | $1,190.00 | Approved |
| CLM-2026-015901 | 2026-03-25 | Northgate Internal Medicine Associates | $281.00 | 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
Exact duplicate of an earlier submission.