CLM-2026-032659
Pinecrest Heart Institute, Cardiology. Service 2026-08-03 at office (POS 11). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Ryan Riley
- Member ID
- UHC-78345-09
- Date of birth
- 1987-02-22
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-411706
- Relationship
- Spouse, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-3532
- Coverage period
- 2022-09-01 to present
- Deductible
- $373.15 of $500.0075%
- Out-of-pocket maximum
- $329.70 of $1,000.0033%
- Copays
- office $25.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8218526324
- Network
- In network
- Rendering NPI
- 4290196524
- Location
- Mesa, AZ · TIN 32-1379406
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $253.00 | $156.86 | — | — | DeniedCO18 |
| 2 | 93224 | Holter monitor, 48 hours | 25 | 1 | 1,2 | $321.00 | $199.02 | — | — | DeniedCO18 |
| Totals | $574.00 | $355.88 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-744491
- 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-028577 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-03: SELECT-EPO (EPO), effective 2022-09-01. | |
| Timely filing | Pass | Received 57 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-032658: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| 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 Institute2026-08-03 15:37
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-29 06:08
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-032658: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032658 | 2026-08-03 | Pinecrest Heart Institute | $574.00 | Approved |
| CLM-2026-020347 | 2026-04-20 | Sunrise Skin Care Associates | $586.00 | Denied |
| CLM-2026-020346 | 2026-04-20 | Sunrise Skin Care Associates | $586.00 | 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
Exact duplicate of an earlier submission.