CLM-2026-030232
Pinecrest Heart Institute, Cardiology. Service 2026-02-17 at outpatient hospital (POS 22). Received 2026-03-20.
Member
Resolved through the identity graph
- Member
- Susan Morris
- Member ID
- UHC-02849-78
- Date of birth
- 1958-03-10
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-402198
- Relationship
- Child, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-8977
- Coverage period
- 2024-10-01 to present
- Deductible
- $846.39 of $1,500.0056%
- Out-of-pocket maximum
- $1,124.62 of $3,000.0037%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 2808839296
- Location
- Mesa, AZ · TIN 32-1379406
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,196.00 | $657.80 | $654.87 | $2.93 | Paid |
| Totals | $1,196.00 | $657.80 | $654.87 | $2.93 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-784350
- 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-013825 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-17: UNKNOWN (PPO), effective 2024-10-01. | |
| Timely filing | Pass | Received 31 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 Institute2026-02-17 12:52
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Itemized billitemized_PA-784350.pdf9 pages
Itemised statement totalling $1196.00 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-2026-033004 | 2026-05-14 | Summit Primary Care Associates | $229.00 | Approved |
| CLM-2026-008925 | 2026-03-09 | Heritage Internal Medicine Associates | $161.00 | Approved |
| CLM-2026-004103 | 2026-01-03 | Lakeside Medical Group | $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.