CLM-2026-003253
Desert Internal Medicine Associates, Internal Medicine. Service 2025-12-25 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Gabriel Robertson
- Member ID
- UHC-65311-64
- Date of birth
- 1946-05-09
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-401400
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7294
- Coverage period
- 2023-02-01 to present
- Deductible
- $379.68 of $1,500.0025%
- Out-of-pocket maximum
- $300.42 of $4,500.007%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3013140306
- Network
- In network
- Rendering NPI
- 9048695958
- Location
- Tempe, AZ · TIN 35-1948033
- Authorisation / referral
- PA2026048335 / REF155597
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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,210.00 | $1,215.50 | — | — | Review |
| Totals | $2,210.00 | $1,215.50 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- 3. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-249653
- 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-001760 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-25: NAVIGATE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026048335 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Internal Medicine Associates (3013140306). | |
| Medical necessity | Review | CO50 | 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity. Not medically necessary per payer policy |
| 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: Desert Internal Medicine Associates2025-12-25 11:56
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-06 06:52
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-06 12:48
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026048335_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-25 to 2026-03-25.
- Itemized billitemized_PA-249653.pdf8 pages
Itemised statement totalling $2210.00 across 1 line.
- Medical recordrecords_PA-249653.pdf13 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:14The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not document any acute findings or red-flag symptoms [N1]. The service is not medically necessary as per payer policy [L1]. The examiner's note indicates that the claim was held for this reason [N3].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · b3d33ba0
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-034460 | 2026-05-02 | Riverside Internal Medicine Associates | $293.00 | Denied |
| CLM-2026-034459 | 2026-05-02 | Heritage Medical Group | $293.00 | Approved |
| CLM-2026-021608 | 2026-04-28 | Valley Imaging Center | $3,807.00 | Needs review |
| CLM-2026-011533 | 2026-02-17 | Desert Regional Medical Center | $1,061.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not document any acute findings or red-flag symptoms [N1]. The service is not medically necessary as per payer policy [L1]. The examiner's note indicates that the claim was held for this reason [N3].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.