CLM-2026-028563
Pinecrest Heart Institute, Cardiology. Service 2026-06-23 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Kenneth Reyes
- Member ID
- UHC-43176-47
- Date of birth
- 1956-06-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-415154
- Relationship
- Child, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2226
- Coverage period
- 2023-05-01 to present
- Deductible
- $5.50 of $500.001%
- Out-of-pocket maximum
- $150.74 of $1,000.0015%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 7937317957
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- none / REF475132
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $653.00 | $359.15 | $359.15 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,004.00 | $552.20 | $260.41 | $291.79 | Paid |
| Totals | $1,657.00 | $911.35 | $619.56 | $291.79 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-610354
- 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-011399 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-23: NAVIGATE-HMO (HMO), effective 2023-05-01. | |
| Timely filing | Pass | Received 4 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 Heart Institute (8218526324). | |
| 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 Heart Institute2026-06-23 10:50
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-610354.pdf6 pages
Itemised statement totalling $1657.00 across 2 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.