CLM-2026-033737
Pinecrest Cardiovascular Associates, Cardiology. Service 2026-08-09 at outpatient hospital (POS 22). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Emily Sanders
- Member ID
- UHC-15252-88
- Date of birth
- 1943-06-20
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-413446
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4611
- Coverage period
- 2022-10-01 to present
- Deductible
- $2,001.72 of $3,500.0057%
- Out-of-pocket maximum
- $251.05 of $10,500.002%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4926340728
- Network
- In network
- Rendering NPI
- 9933832567
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $927.00 | $509.85 | $509.85 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 2 | $588.00 | $323.40 | $323.40 | $0.00 | Paid |
| Totals | $1,515.00 | $833.25 | $833.25 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-648325
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-017977 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-09: - (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 45 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 Associates2026-08-09 14:50
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-648325.pdf7 pages
Itemised statement totalling $1515.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003086 | 2026-05-23 | Valley Imaging Center | $3,107.00 | Approved |
| CLM-2026-030349 | 2026-02-07 | Meadow Internal Medicine Associates | $377.00 | 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.