CLM-2026-003506
Northgate Cardiovascular Associates, Cardiology. Service 2025-12-24 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Joshua Holmes
- Member ID
- UHC-28099-06
- Date of birth
- 1977-04-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-408579
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9480
- Coverage period
- 2023-12-01 to present
- Deductible
- $38.66 of $1,500.003%
- Out-of-pocket maximum
- $871.87 of $4,500.0019%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 8519966328
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- PA2025980476 / REF329725
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 | $2,968.00 | $1,632.40 | — | — | Review |
| Totals | $2,968.00 | $1,632.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-822468
- 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-000524 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-24: NAVIGATE-HMO (HMO), effective 2023-12-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025980476 on file for 70553. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (5594465275). | |
| 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: Northgate Cardiovascular Associates2025-12-24 18:34
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 system2026-01-02 02:21
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 letterPA2025980476_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-24 to 2026-03-24.
- Itemized billitemized_PA-822468.pdf6 pages
Itemised statement totalling $2968.00 across 1 line.
- Medical recordrecords_PA-822468.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 engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:05The 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, red-flag symptoms, or failed conservative treatment. Therefore, the service is not medically necessary per payer policy [N1], [A3].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · f5d2f487
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031938 | 2026-05-15 | Cornerstone Orthopedic Specialists | $159.00 | Denied |
| CLM-2026-003075 | 2026-02-09 | Lakeside Bone and Joint Center | $37,403.00 | Needs review |
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, red-flag symptoms, or failed conservative treatment. Therefore, the service is not medically necessary per payer policy [N1], [A3].
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.