CLM-2026-006650
Evergreen Diagnostic Imaging, Radiology. Service 2025-12-27 at outpatient hospital (POS 22). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Jon Parker
- Member ID
- UHC-53297-26
- Date of birth
- 1952-09-07
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-412527
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5255
- Coverage period
- 2023-08-01 to present
- Deductible
- $2,040.64 of $2,500.0082%
- Out-of-pocket maximum
- $924.51 of $10,000.009%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Diagnostic ImagingRadiology · taxonomy 2085R0202X
- NPI
- 7098075170
- Network
- In network
- Rendering NPI
- 7098075170
- Location
- Atlanta, GA · TIN 75-1814880
- Authorisation / referral
- PA2025935411 / 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 | 59 | 1 | 1 | $3,338.00 | $1,835.90 | — | — | Review |
| 2 | 74177 rev 0350 | CT abdomen and pelvis with contrast | 59 | 1 | 1 | $2,388.00 | $1,313.40 | — | — | Review |
| Totals | $5,726.00 | $3,149.30 | — | — | ||||||
- 1. R51.9 Headache, unspecifiedprincipal
- 2. R07.9 Chest pain, unspecified
- 3. R10.9 Unspecified abdominal pain
- Patient account
- PA-214658
- 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-000908 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-27: MEDICARE-ADV-B (MA), effective 2023-08-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025935411 on file for 70553, 74177. | |
| Provider network | Pass | In-network provider Evergreen Diagnostic Imaging (7098075170). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Review | CO97 | Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated |
| 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 Diagnostic Imaging2025-12-27 17:43
Patient seen for headache, unspecified. Both procedures were performed at the same site during the same session as part of one service.
- SystemSystem: Claims system2026-01-03 04:00
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
Attachments
Documents received with the claim
- Prior auth letterPA2025935411_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-27 to 2026-03-27.
- Itemized billitemized_PA-214658.pdf2 pages
Itemised statement totalling $5726.00 across 2 lines.
- Medical recordrecords_PA-214658.pdf9 pages
Operative note describes a single procedure at one site; no separate session.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.
- AI recommendationDenied2026-10-21 14:05The claim includes procedures 70553 and 74177, which are normally bundled. The clinical note [N1] states that both procedures were performed at the same site during the same session as part of one service. The use of modifier 59 is not supported by the documentation, as required by the NCCI edit [R-ncci]. Therefore, the claim is denied for CO97, as the benefit is included in another service already adjudicated.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 80d91603
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014535 | 2026-05-30 | Riverside Orthopedic Specialists | $220.00 | Approved |
| CLM-2026-014927 | 2026-03-12 | Unity Cardiovascular Associates | $410.00 | Approved |
| CLM-2026-017553 | 2026-01-13 | Pinecrest Bone and Joint Center | $202.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO97 Benefit included in another service already adjudicated
The claim includes procedures 70553 and 74177, which are normally bundled. The clinical note [N1] states that both procedures were performed at the same site during the same session as part of one service. The use of modifier 59 is not supported by the documentation, as required by the NCCI edit [R-ncci]. Therefore, the claim is denied for CO97, as the benefit is included in another service already adjudicated.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO97 Benefit included in another service already adjudicated
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Bundled code pair; modifier 59 not supported by the operative note.