CLM-2026-025838
Pinecrest Diagnostic Imaging, Radiology. Service 2026-02-12 at outpatient hospital (POS 22). Received 2026-02-27.
Member
Resolved through the identity graph
- Member
- Bruce Johnston
- Member ID
- UHC-32734-85
- Date of birth
- 1957-08-10
- Identity
- Verified6 records, confidence 0.87
- Claim record
- CLMCLM-402141
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7041
- Coverage period
- 2023-08-01 to present
- Deductible
- $1,948.85 of $2,500.0078%
- Out-of-pocket maximum
- $2,481.96 of $5,000.0050%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 8391485629
- Network
- In network
- Rendering NPI
- 8391485629
- Location
- Scottsdale, AZ · TIN 15-2373170
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $122.00 | $67.10 | — | — | Review |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $322.00 | $177.10 | — | — | Review |
| Totals | $444.00 | $244.20 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-650662
- 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-008126 (verified, link confidence 0.87). | |
| Eligibility | Pass | Active on 2026-02-12: SELECT-EPO (EPO), effective 2023-08-01. | |
| Timely filing | Pass | Received 15 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 (8391485629). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Pinecrest Diagnostic Imaging2026-02-12 09:18
Patient seen for chest pain, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-27 04:51
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-650662.pdf4 pages
Itemised statement totalling $444.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-022976 | 2026-05-27 | Evergreen Primary Care Associates | $371.00 | Approved |
| CLM-2026-012582 | 2026-03-30 | Desert Internal Medicine Associates | $260.00 | Approved |
| CLM-2026-011929 | 2026-03-13 | Northgate Bone and Joint Center | $1,168.00 | Denied |
| CLM-2026-013241 | 2026-01-09 | Harbor Digestive Health Center | $1,307.00 | Approved |
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
Development letter outstanding.