CLM-2026-024213
Pinecrest Heart Institute, Cardiology. Service 2026-06-05 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Camila Ortiz
- Member ID
- UHC-05912-11
- Date of birth
- 2008-06-21
- Identity
- Verified6 records, confidence 0.93
- Claim record
- CLMCLM-414296
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9032
- Coverage period
- 2021-10-01 to 2026-05-23
- Deductible
- $425.05 of $1,500.0028%
- Out-of-pocket maximum
- $2,182.65 of $6,000.0036%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 4184918983
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- none / REF749078
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $273.00 | $169.26 | — | — | DeniedCO27 |
| Totals | $273.00 | $169.26 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-354985
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-038267 (verified, link confidence 0.93). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-05 is after coverage terminated on 2026-05-23. Expenses incurred after coverage terminated |
| Timely filing | Fail | CO29 | Received 112 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Heart Institute (8218526324). | |
| 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 Heart Institute2026-06-05 10:32
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-09-25 02:48
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-25 13:23
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-05 is after coverage terminated on 2026-05-23. Timely filing: Received 112 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030433 | 2026-08-03 | Northgate Dermatology Clinic | $739.00 | Denied |
| CLM-2026-022604 | 2026-07-31 | Lakeside Reference Lab | $98.00 | Denied |
| CLM-2026-020139 | 2026-06-19 | Meadow Physical Therapy | $289.00 | Denied |
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.