CLM-2026-007125
Valley Primary Care Associates, Family Medicine. Service 2025-12-19 at outpatient hospital (POS 22). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Albert Hall
- Member ID
- none on golden record
- Date of birth
- 1980-03-18
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405293
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- SELECT-EPO EPO group UNKNOWN
- Coverage period
- 2025-07-01 to present
- Deductible
- $361.87 of $2,500.0014%
- Out-of-pocket maximum
- $1,177.73 of $10,000.0012%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 6179468650
- Network
- Out of network
- Rendering NPI
- 7931614870
- Location
- Denver, CO · TIN 69-3521502
- Authorisation / referral
- PA2025596064 / 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 | $3,248.00 | $1,461.60 | — | — | DeniedCO204 |
| Totals | $3,248.00 | $1,461.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-329133
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 4 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000909; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-19: SELECT-EPO (EPO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| 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 PA2025596064 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 6179468650 is out of network and the EPO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Valley Primary Care Associates2025-12-19 16:56
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-01-10 03:26
Billing provider is out of network and the member's plan has no out-of-network benefit outside of emergencies.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-10 16:31
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025596064_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-19 to 2026-03-19.
- Itemized billitemized_PA-329133.pdf7 pages
Itemised statement totalling $3248.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Member identity: Member record is in open steward case CASE-000909; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-19: SELECT-EPO (EPO), effective 2025-07-01. Coverage found by name and date of birth because the claim carried no usable member ID. Provider network: Billing provider 6179468650 is out of network and the EPO plan has no out-of-network benefit. 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
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
No out-of-network benefit on this plan.