CLM-2026-028505
Pinecrest Diagnostic Imaging, Radiology. Service 2026-05-21 at outpatient hospital (POS 22). Received 2026-06-14.
Member
Resolved through the identity graph
- Member
- Benjamin Palmer
- Member ID
- UHC-36420-96
- Date of birth
- 1995-08-28
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-425577
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- - PPO group UNKNOWN
- Coverage period
- 2021-11-01 to present
- Deductible
- $401.43 of $2,500.0016%
- Out-of-pocket maximum
- $1,274.61 of $7,500.0017%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 3 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
- PA2026488974 / 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 | 74177 rev 0350 | CT abdomen and pelvis with contrast | — | 1 | 1 | $1,319.00 | $725.45 | $725.45 | $0.00 | Paid |
| 2 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 1 | $309.00 | $169.95 | $169.95 | $0.00 | Paid |
| 3 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 2 | $564.00 | $310.20 | $310.20 | $0.00 | Paid |
| Totals | $2,192.00 | $1,205.60 | $1,205.60 | $0.00 | ||||||
- 1. M25.561 Pain in right kneeprincipal
- 2. R51.9 Headache, unspecified
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-193023
- 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-031175 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-21: - (PPO), effective 2021-11-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026488974 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 Imaging2026-05-21 15:28
Patient seen for pain in right knee.
Attachments
Documents received with the claim
- Prior auth letterPA2026488974_approval.pdf2 pages
Utilisation management approval letter for 74177 (CT abdomen and pelvis with contrast), valid 2026-05-21 to 2026-08-19.
- Itemized billitemized_PA-193023.pdf6 pages
Itemised statement totalling $2192.00 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
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.