CLM-2026-005757
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2026-01-15 at outpatient hospital (POS 22). Received 2026-01-25.
Member
Resolved through the identity graph
- Member
- Maria Cooper
- Member ID
- UHC-53767-89
- Date of birth
- 1963-02-22
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-407543
- Relationship
- Self, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0386
- Coverage period
- 2022-08-01 to present
- Deductible
- $233.93 of $500.0047%
- Out-of-pocket maximum
- $391.67 of $1,000.0039%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- Authorisation / referral
- PA2025430504 / REF889018
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 | $3,066.00 | $1,686.30 | — | — | Review |
| Totals | $3,066.00 | $1,686.30 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-689792
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-007490 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-15: CORE-HMO (HMO), effective 2022-08-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025430504 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Clinical Laboratories (8920689386). | |
| 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: Lakeside Clinical Laboratories2026-01-15 15:55
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-25 05:53
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 letterPA2025430504_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-15 to 2026-04-15.
- Itemized billitemized_PA-689792.pdf3 pages
Itemised statement totalling $3066.00 across 1 line.
- Medical recordrecords_PA-689792.pdf19 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018897 | 2026-07-25 | Pinecrest Regional Medical Center | $3,100.00 | Approved |
| CLM-2026-012066 | 2026-04-01 | Meadow Reference Lab | $187.00 | Denied |
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
Routine diagnosis does not support advanced imaging.