CLM-2026-006200
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-07-05 at outpatient hospital (POS 22). Received 2026-07-27.
Member
Resolved through the identity graph
- Member
- Cynthia Sandoval
- Member ID
- UHC-40936-82
- Date of birth
- 2002-04-06
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-413490
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0371
- Coverage period
- 2022-02-01 to present
- Deductible
- $956.33 of $1,500.0064%
- Out-of-pocket maximum
- $2,241.99 of $4,500.0050%
- Copays
- office $25.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4514050481
- Network
- In network
- Rendering NPI
- 4514050481
- Location
- Tempe, AZ · TIN 12-2226671
- Authorisation / referral
- PA2025617323 / 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 | $2,608.00 | $1,434.40 | — | — | Review |
| Totals | $2,608.00 | $1,434.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-208444
- 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-003561 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-05: UNKNOWN (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025617323 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Clinical Laboratories (4514050481). | |
| 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: Riverside Clinical Laboratories2026-07-05 13:15
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 system2026-07-27 00:03
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 letterPA2025617323_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-05 to 2026-10-03.
- Itemized billitemized_PA-208444.pdf5 pages
Itemised statement totalling $2608.00 across 1 line.
- Medical recordrecords_PA-208444.pdf16 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032190 | 2026-10-01 | Canyon Clinical Laboratories | $45.00 | Approved |
| CLM-2026-025864 | 2026-08-05 | Desert Internal Medicine Associates | $163.00 | Approved |
| CLM-2026-018071 | 2026-07-14 | Sunrise Internal Medicine Associates | $335.00 | Approved |
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.