CLM-2026-005011
Summit Regional Medical Center, Emergency Medicine. Service 2025-11-21 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Maria Meyer
- Member ID
- UHC-73025-52
- Date of birth
- 1957-11-25
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-416208
- Relationship
- Self, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6844
- Coverage period
- 2024-02-01 to present
- Deductible
- $367.66 of $1,000.0037%
- Out-of-pocket maximum
- $856.56 of $4,000.0021%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7959926214
- Network
- In network
- Rendering NPI
- 7959926214
- Location
- Mesa, AZ · TIN 13-8570749
- Authorisation / referral
- PA2025769522 / 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 | $3,280.00 | $1,804.00 | — | — | Review |
| Totals | $3,280.00 | $1,804.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-281360
- 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-001540 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-21: SELECT-EPO (EPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025769522 on file for 70553. | |
| Provider network | Pass | In-network provider Summit Regional Medical Center (7959926214). | |
| 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: Summit Regional Medical Center2025-11-21 18:33
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. 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 system2026-01-05 03:18
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 letterPA2025769522_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-11-21 to 2026-02-19.
- Itemized billitemized_PA-281360.pdf5 pages
Itemised statement totalling $3280.00 across 1 line.
- Medical recordrecords_PA-281360.pdf5 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 ([A1]) and clinical notes ([N1], [A3]) that document failed conservative therapy and progressive neurological symptoms, which justify the medical necessity of the imaging. The provider is in-network ([PRV]), and the member is eligible ([IDN], [COV]). All deterministic rules passed, and the clinical edit flag was resolved by the clinical note. The billed amount is within the auto-adjudication ceiling, and the claim is complete.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 9439bd86
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029692 | 2026-01-24 | Meadow Medical Group | $226.00 | Approved |
| CLM-2026-002340 | 2026-02-07 | Cornerstone Bone and Joint Center | $11,725.00 | 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 ([A1]) and clinical notes ([N1], [A3]) that document failed conservative therapy and progressive neurological symptoms, which justify the medical necessity of the imaging. The provider is in-network ([PRV]), and the member is eligible ([IDN], [COV]). All deterministic rules passed, and the clinical edit flag was resolved by the clinical note. The billed amount is within the auto-adjudication ceiling, and the claim is complete.
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.