CLM-2026-029158
Pinecrest Diagnostic Imaging, Radiology. Service 2025-11-01 at outpatient hospital (POS 22). Received 2026-05-10.
Member
Resolved through the identity graph
- Member
- Donna Perez
- Member ID
- UHC-15786-23
- Date of birth
- 2005-06-03
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-401645
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-9200
- Coverage period
- 2025-06-01 to present
- Deductible
- $561.47 of $1,500.0037%
- Out-of-pocket maximum
- $929.13 of $6,000.0015%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 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
- 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 | 71046 rev 0320 | Chest X-ray, two views | — | 1 | 1 | $116.00 | $63.80 | — | — | DeniedCO29 |
| 2 | 76700 rev 0402 | Ultrasound abdomen, complete | — | 1 | 1 | $420.00 | $231.00 | — | — | DeniedCO29 |
| 3 | 77067 rev 0403 | Screening mammography, bilateral | — | 1 | 2 | $418.00 | $229.90 | — | — | DeniedCO29 |
| Totals | $954.00 | $524.70 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-383972
- 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-009739 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-01: OPTIONS-PPO (PPO), effective 2025-06-01. | |
| Timely filing | Fail | CO29 | Received 190 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (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 Imaging2025-11-01 12:18
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-05-10 04:12
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-383972.pdf3 pages
Itemised statement totalling $954.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 190 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033360 | 2026-10-09 | Meadow GI Associates | $323.00 | Approved |
| CLM-2026-017052 | 2026-01-08 | Heritage Primary Care Associates | $216.00 | Needs review |
| CLM-2026-021150 | 2025-12-27 | Valley Digestive Health Center | $1,955.00 | Approved |
| CLM-2026-017051 | 2026-01-08 | Lakeside Medical Group | $216.00 | 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
Received after the timely-filing limit.