CLM-2026-003895
Mesa Medical Group, Family Medicine. Service 2026-09-06 at outpatient hospital (POS 22). Received 2026-09-14.
Member
Resolved through the identity graph
- Member
- Brittany Warren
- Member ID
- UHC-22159-07
- Date of birth
- 2008-09-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401975
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group -
- Coverage period
- 2021-02-01 to 2026-05-21
- Deductible
- $2,140.22 of $3,500.0061%
- Out-of-pocket maximum
- $1,777.79 of $7,000.0025%
- Copays
- office $40.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 3131727711
- Network
- In network
- Rendering NPI
- 3552154122
- Location
- Dallas, TX · TIN 70-1042424
- Authorisation / referral
- PA2025562830 / 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 | $2,905.00 | $1,597.75 | — | — | DeniedCO27 |
| Totals | $2,905.00 | $1,597.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. M54.50 Low back pain, unspecified
- Patient account
- PA-745441
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032180 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-09-06 is after coverage terminated on 2026-05-21. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 8 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025562830 on file for 70553. | |
| Provider network | Pass | In-network provider Mesa Medical Group (3131727711). | |
| 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: Mesa Medical Group2026-09-06 09:52
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-09-14 06:53
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-09-14 13:29
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025562830_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-06 to 2026-12-05.
- Itemized billitemized_PA-745441.pdf8 pages
Itemised statement totalling $2905.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-09-06 is after coverage terminated on 2026-05-21. Medical necessity: 70553 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.