CLM-2026-025992
Pinecrest Diagnostic Imaging, Radiology. Service 2026-09-29 at outpatient hospital (POS 22). Received 2026-10-04.
Member
Resolved through the identity graph
- Member
- Raymond Banks
- Member ID
- UHC-72994-01
- Date of birth
- 1966-04-28
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-414138
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5869
- Coverage period
- 2023-04-01 to 2026-08-26
- Deductible
- $243.50 of $1,500.0016%
- Out-of-pocket maximum
- $701.34 of $3,000.0023%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 19 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 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $573.00 | $315.15 | — | — | DeniedCO27 |
| 2 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $133.00 | $73.15 | — | — | DeniedCO27 |
| Totals | $706.00 | $388.30 | — | — | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-181701
- 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-007745 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-29 is after coverage terminated on 2026-08-26. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 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 | 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 Imaging2026-09-29 18:01
Patient seen for pain in right knee.
- SystemSystem: Claims system2026-10-04 05:27
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-10-04 10:22
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-181701.pdf3 pages
Itemised statement totalling $706.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-09-29 is after coverage terminated on 2026-08-26.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018918 | 2026-05-29 | Lakeside Internal Medicine Associates | $149.00 | Approved |
| CLM-2026-004463 | 2026-03-14 | Northgate Clinical Laboratories | $249.00 | Needs review |
| CLM-2026-004462 | 2026-03-14 | Northgate Clinical Laboratories | $249.00 | Approved |
| CLM-2026-006765 | 2026-02-14 | Sunrise Dermatology Clinic | $470.00 | Approved |
| CLM-2026-000921 | 2025-12-17 | Lakeside Reference Lab | $64.00 | 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
Service after coverage termination.