CLM-2026-026487
Pinecrest Diagnostic Imaging, Radiology. Service 2026-04-17 at outpatient hospital (POS 22). Received 2026-05-25.
Member
Resolved through the identity graph
- Member
- Angela Mills
- Member ID
- UHC-64081-98
- Date of birth
- 1973-10-09
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401077
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group N/A
- Coverage period
- 2025-09-01 to present
- Deductible
- $123.83 of $1,500.008%
- Out-of-pocket maximum
- $1,374.60 of $3,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 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
- PA2025707860 / 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 | $221.00 | $121.55 | $121.55 | $0.00 | Paid |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $2,269.00 | $1,247.95 | $1,247.95 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $520.00 | $286.00 | $90.47 | $195.53 | Paid |
| Totals | $3,010.00 | $1,655.50 | $1,459.97 | $195.53 | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- Patient account
- PA-828429
- 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-001419 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-17: OPTIONS-PPO (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025707860 on file for 74177. | |
| 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 Imaging2026-04-17 17:41
Established patient presents with headache, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025707860_approval.pdf2 pages
Utilisation management approval letter for 71046 (Chest X-ray, two views), valid 2026-04-17 to 2026-07-16.
- Itemized billitemized_PA-828429.pdf3 pages
Itemised statement totalling $3010.00 across 3 lines.
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-2026-008664 | 2026-05-21 | Unity Cardiovascular Associates | $582.00 | Approved |
| CLM-2026-016606 | 2026-03-09 | Mesa Bone and Joint Center | $1,486.00 | 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.