CLM-2026-005364
Heritage Family Practice, Family Medicine. Service 2025-11-23 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Amber Lee
- Member ID
- UHC-32742-91
- Date of birth
- 2004-04-08
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-427624
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4648
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,357.98 of $2,500.0054%
- Out-of-pocket maximum
- $522.26 of $5,000.0010%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3586851693
- Network
- In network
- Rendering NPI
- 7906128518
- Location
- Scottsdale, AZ · TIN 98-1410500
- Authorisation / referral
- PA2025703332 / 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 | $2,457.00 | $1,351.35 | — | — | Review |
| Totals | $2,457.00 | $1,351.35 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-868778
- 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-000268 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-23: SELECT-EPO (EPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025703332 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Family Practice (3586851693). | |
| 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: Heritage Family Practice2025-11-23 13:09
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-01-01 01:34
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 letterPA2025703332_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-11-23 to 2026-02-21.
- Itemized billitemized_PA-868778.pdf7 pages
Itemised statement totalling $2457.00 across 1 line.
- Medical recordrecords_PA-868778.pdf12 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 (PA2025703332) and clinical notes (N1) that document failed conservative therapy and progressive neurological symptoms, which justify the medical necessity of the imaging. The member is eligible and the provider is in-network. The claim is within the timely filing limit and does not exceed the auto-adjudication ceiling. However, the billed amount is above $15,000.00, requiring human sign-off.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · aec51bcc
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005875 | 2026-06-13 | Desert Medical Group | $359.00 | 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 (PA2025703332) and clinical notes (N1) that document failed conservative therapy and progressive neurological symptoms, which justify the medical necessity of the imaging. The member is eligible and the provider is in-network. The claim is within the timely filing limit and does not exceed the auto-adjudication ceiling. However, the billed amount is above $15,000.00, requiring human sign-off.
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.