CLM-2026-029514
Pinecrest Diagnostic Imaging, Radiology. Service 2026-01-11 at outpatient hospital (POS 22). Received 2026-01-20.
Member
Resolved through the identity graph
- Member
- Douglas Kelly
- Member ID
- UHC-63043-26
- Date of birth
- 1995-05-25
- Identity
- Verified4 records, confidence 0.86
- Claim record
- CLMCLM-428626
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-6952
- Coverage period
- 2022-12-01 to present
- Deductible
- $722.20 of $1,500.0048%
- Out-of-pocket maximum
- $1,132.24 of $3,000.0038%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 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
- 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 | $176.00 | $96.80 | $96.80 | $0.00 | Paid |
| Totals | $176.00 | $96.80 | $96.80 | $0.00 | ||||||
- 1. R10.9 Unspecified abdominal painprincipal
- Patient account
- PA-974409
- 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-001670 (verified, link confidence 0.86). | |
| Eligibility | Pass | Active on 2026-01-11: N/A (PPO), effective 2022-12-01. | |
| Timely filing | Pass | Received 9 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 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 Imaging2026-01-11 10:24
Follow-up for unspecified abdominal pain. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-974409.pdf2 pages
Itemised statement totalling $176.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002451 | 2026-08-03 | Cornerstone Cardiovascular Associates | $297.00 | 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.