CLM-2026-025282
Pinecrest Diagnostic Imaging, Radiology. Service 2026-07-17 at outpatient hospital (POS 22). Received 2026-07-28.
Member
Resolved through the identity graph
- Member
- Joyce Morrison
- Member ID
- UHC-87643-47
- Date of birth
- 2008-07-04
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-410578
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4633
- Coverage period
- 2025-11-01 to present
- Deductible
- $351.00 of $3,500.0010%
- Out-of-pocket maximum
- $2,423.63 of $14,000.0017%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 12 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
- PA2025894129 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $3,331.00 | $1,832.05 | $1,832.05 | $0.00 | Paid |
| Totals | $3,331.00 | $1,832.05 | $1,832.05 | $0.00 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. M25.561 Pain in right knee
- Patient account
- PA-131311
- 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-010605 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-17: OPTIONS-PPO (PPO), effective 2025-11-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025894129 on file for 70553. | |
| 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 Imaging2026-07-17 14:47
Follow-up for headache, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2025894129_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-17 to 2026-10-15.
- Itemized billitemized_PA-131311.pdf6 pages
Itemised statement totalling $3331.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011765 | 2026-01-05 | Harbor Rehabilitation Center | $560.00 | Approved |
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.