CLM-2026-007671
Harbor Rehabilitation Center, Physical Therapy. Service 2025-12-20 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Tyler Morris
- Member ID
- UHC-22612-53
- Date of birth
- 1966-01-12
- Identity
- Verified2 records, confidence 1.00
- Claim record
- CLMCLM-421909
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6533
- Coverage period
- 2023-02-01 to present
- Deductible
- $437.62 of $500.0088%
- Out-of-pocket maximum
- $383.20 of $2,000.0019%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Rehabilitation CenterPhysical Therapy · taxonomy 225100000X
- NPI
- 1139592160
- Network
- In network
- Rendering NPI
- 4000145886
- Location
- Mesa, AZ · TIN 48-8489623
- Authorisation / referral
- PA2025840758 / REF400523
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 | — | 3 | 1 | $9,804.00 | $5,392.20 | — | — | Review |
| Totals | $9,804.00 | $5,392.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-860950
- 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-001275 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-20: NAVIGATE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 16 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025840758 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Rehabilitation Center (1139592160). | |
| 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: Harbor Rehabilitation Center2025-12-20 16:09
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 system2026-01-05 06:28
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 letterPA2025840758_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-20 to 2026-03-20.
- Itemized billitemized_PA-860950.pdf3 pages
Itemised statement totalling $9804.00 across 1 line.
- Medical recordrecords_PA-860950.pdf15 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:05The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings. The clinical note [N1] and medical record [A3] do not document any acute findings, red-flag symptoms, or failed conservative treatment that would justify the advanced imaging. Therefore, the service is not medically necessary per payer policy, and the claim is denied with reason code CO50.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 9e775862
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings. The clinical note [N1] and medical record [A3] do not document any acute findings, red-flag symptoms, or failed conservative treatment that would justify the advanced imaging. Therefore, the service is not medically necessary per payer policy, and the claim is denied with reason code CO50.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.