CLM-2026-005640
Mesa Medical Group, Family Medicine. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-05-24.
Member
Resolved through the identity graph
- Member
- Eliijah Mitchell
- Member ID
- none on golden record
- Date of birth
- 1998-11-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-426031
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 9868639979
- Location
- Los Angeles, CA · TIN 30-7296562
- Authorisation / referral
- PA2025120923 / 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 | $3,381.00 | $1,859.55 | — | — | PendedIDQ |
| Totals | $3,381.00 | $1,859.55 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-264772
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-004004; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025120923 on file for 70553. | |
| Provider network | Pass | In-network provider Mesa Medical Group (7662849547). | |
| 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 Group2026-05-18 15:17
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-24 03:45
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-05-24 08:57
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025120923_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-18 to 2026-08-16.
- Itemized billitemized_PA-264772.pdf6 pages
Itemised statement totalling $3381.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-004004; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim. 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
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.