CLM-2026-003393
Unity Bone and Joint Center, Orthopedic Surgery. Service 2026-07-26 at outpatient hospital (POS 22). Received 2026-08-19.
Member
Resolved through the identity graph
- Member
- Mason Moore
- Member ID
- UHC-10777-03
- Date of birth
- 1976-10-05
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-409614
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-1034
- Coverage period
- 2022-01-01 to present
- Deductible
- $1,959.61 of $2,500.0078%
- Out-of-pocket maximum
- $1,210.17 of $7,500.0016%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Bone and Joint CenterOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 5039337832
- Network
- In network
- Rendering NPI
- 7269767795
- Location
- Los Angeles, CA · TIN 56-0316152
- Authorisation / referral
- PA2025553673 / 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 | $3,437.00 | $1,890.35 | — | — | Review |
| 2 | 73721 rev 0610 | MRI lower extremity joint without contrast | — | 1 | 1 | $1,328.00 | $730.40 | — | — | Review |
| Totals | $4,765.00 | $2,620.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-804564
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022235 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-26: UNKNOWN (PPO), effective 2022-01-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025553673 on file for 70553, 73721. | |
| Provider network | Pass | In-network provider Unity Bone and Joint Center (5039337832). | |
| Medical necessity | Review | CO50 | 70553, 73721 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 Bone and Joint Center2026-07-26 11:20
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-08-19 03:33
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-08-19 13:28
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025553673_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-26 to 2026-10-24.
- Itemized billitemized_PA-804564.pdf8 pages
Itemised statement totalling $4765.00 across 2 lines.
- Medical recordrecords_PA-804564.pdf20 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553, 73721 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Routine diagnosis does not support advanced imaging.