CLM-2026-033192
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-05-06 at outpatient hospital (POS 22). Received 2026-06-07.
Member
Resolved through the identity graph
- Member
- Marcus White
- Member ID
- UHC-00927-15
- Date of birth
- 1984-02-10
- Identity
- Verified4 records, confidence 0.85
- Claim record
- CLMCLM-413370
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-6410
- Coverage period
- 2025-01-01 to present
- Deductible
- $295.56 of $500.0059%
- Out-of-pocket maximum
- $52.94 of $1,500.004%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 3 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 2665841740
- Location
- Houston, TX · TIN 79-8590773
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $448.00 | $246.40 | $208.64 | $37.76 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $968.00 | $532.40 | $53.24 | $479.16 | Paid |
| Totals | $1,416.00 | $778.80 | $261.88 | $516.92 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-239420
- 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-025905 (verified, link confidence 0.85). | |
| Eligibility | Pass | Active on 2026-05-06: MEDICARE-ADV-B (MA), effective 2025-01-01. | |
| Timely filing | Pass | Received 32 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 Cardiovascular Associates (4926340728). | |
| 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 Cardiovascular Associates2026-05-06 15:53
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-239420.pdf6 pages
Itemised statement totalling $1416.00 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.