CLM-2026-027284
Pinecrest Diagnostic Imaging, Radiology. Service 2025-12-13 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Mateo Snyder
- Member ID
- UHC-26840-16
- Date of birth
- 1984-08-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-401219
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-7832
- Coverage period
- 2023-03-01 to present
- Deductible
- $2,560.91 of $3,500.0073%
- Out-of-pocket maximum
- $1,361.13 of $10,500.0013%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 15 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
- PA2025293524 / 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 | $2,071.00 | $1,139.05 | $959.09 | $179.96 | Paid |
| Totals | $2,071.00 | $1,139.05 | $959.09 | $179.96 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- 2. R07.9 Chest pain, unspecified
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-892929
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000281 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-13: MEDICARE-ADV-B (MA), effective 2023-03-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025293524 on file for 70553. | |
| 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 Imaging2025-12-13 16:16
Patient seen for unspecified abdominal pain.
Attachments
Documents received with the claim
- Prior auth letterPA2025293524_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-13 to 2026-03-13.
- Itemized billitemized_PA-892929.pdf2 pages
Itemised statement totalling $2071.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033919 | 2026-03-31 | Cornerstone Reference Lab | $110.00 | Approved |
| CLM-2026-005642 | 2026-04-22 | Cornerstone Diabetes Center | $416.00 | Approved |
| CLM-2026-027285 | 2025-12-13 | Riverside Imaging Center | $2,071.00 | Needs review |
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.