CLM-2026-005860
Evergreen Family Practice, Family Medicine. Service 2026-05-14 at outpatient hospital (POS 22). Received 2026-05-22.
Member
Resolved through the identity graph
- Member
- Tylr Perry
- Member ID
- UHC-30693-81
- Date of birth
- 1976-09-27
- Identity
- Verified2 records, confidence 0.92
- Claim record
- CLMCLM-417497
- Relationship
- Self, Los Angeles, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group -
- Coverage period
- 2024-11-01 to present
- Deductible
- $2,442.73 of $3,500.0070%
- Out-of-pocket maximum
- $4,687.57 of $10,500.0045%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9423912895
- Network
- In network
- Rendering NPI
- 8506891190
- Location
- Austin, TX · TIN 10-8497097
- Authorisation / referral
- PA2026985588 / 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 | $3,141.00 | $1,727.55 | — | — | Review |
| Totals | $3,141.00 | $1,727.55 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-811305
- 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-008738 (verified, link confidence 0.92). | |
| Eligibility | Pass | Active on 2026-05-14: CHOICE-PLUS-PPO (PPO), effective 2024-11-01. | |
| 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 PA2026985588 on file for 70553. | |
| Provider network | Pass | In-network provider Evergreen Family Practice (9423912895). | |
| 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: Evergreen Family Practice2026-05-14 12:36
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 system2026-05-22 06:48
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-05-22 14:05
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026985588_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-14 to 2026-08-12.
- Itemized billitemized_PA-811305.pdf3 pages
Itemised statement totalling $3141.00 across 1 line.
- Medical recordrecords_PA-811305.pdf15 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 engineReview2026-10-22 12:44Medical 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
Notes document medical necessity.