CLM-2026-003303
Unity Reference Lab, Clinical Laboratory. Service 2025-11-19 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Jennifer Vargas
- Member ID
- UHC-26130-42
- Date of birth
- 1989-11-03
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-423874
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9763
- Coverage period
- 2022-07-01 to present
- Deductible
- $431.78 of $500.0086%
- Out-of-pocket maximum
- $298.66 of $1,500.0020%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4372283836
- Network
- In network
- Rendering NPI
- 4372283836
- Location
- Phoenix, AZ · TIN 58-9749325
- Authorisation / referral
- PA2026792650 / 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 | 70553 rev 0610 | MRI brain with and without contrast | — | 1 | 1 | $2,302.00 | $1,266.10 | — | — | Review |
| Totals | $2,302.00 | $1,266.10 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-358316
- 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-000379 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-11-19: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 44 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026792650 on file for 70553. | |
| Provider network | Pass | In-network provider Unity Reference Lab (4372283836). | |
| 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: Unity Reference Lab2025-11-19 13:42
Patient seen for encounter for general adult medical examination without abnormal findings. Imaging was ordered because of progressive neurological symptoms and failed conservative therapy over 8 weeks; study is medically necessary to rule out structural cause.
- SystemSystem: Claims system2026-01-02 06:03
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2026792650_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-11-19 to 2026-02-17.
- Itemized billitemized_PA-358316.pdf6 pages
Itemised statement totalling $2302.00 across 1 line.
- Medical recordrecords_PA-358316.pdf18 pages
Clinic notes documenting 8 weeks of failed conservative therapy and progressive symptoms.
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 recommendationApproved2026-10-21 14:05The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2026792650) and is medically necessary as documented in the clinical notes [N1] and medical record [A3]. The provider is in-network [R-network], and the claim is within the timely filing limit [R-timely_filing]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and all required documentation is present [R-completeness]. The member is eligible and the identity is verified [R-identity, IDN]. The service is covered under the member's plan [COV, R-eligibility], and there are no bundling conflicts [R-ncci] or benefit limits [R-benefit_limit].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · fedcb1d4
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-012373 | 2026-07-26 | Heritage GI Associates | $310.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2026792650) and is medically necessary as documented in the clinical notes [N1] and medical record [A3]. The provider is in-network [R-network], and the claim is within the timely filing limit [R-timely_filing]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and all required documentation is present [R-completeness]. The member is eligible and the identity is verified [R-identity, IDN]. The service is covered under the member's plan [COV, R-eligibility], and there are no bundling conflicts [R-ncci] or benefit limits [R-benefit_limit].
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Notes document medical necessity.