CLM-2026-009009
Pinecrest Reference Lab, Clinical Laboratory. Service 2025-12-20 at outpatient hospital (POS 22). Received 2026-01-04.
Member
Resolved through the identity graph
- Member
- Bryan McDonald
- Member ID
- UHC-55577-57
- Date of birth
- 1943-01-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401484
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6298
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,654.19 of $3,500.0047%
- Out-of-pocket maximum
- $6,924.67 of $14,000.0049%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 4399070182
- Network
- In network
- Rendering NPI
- 4399070182
- Location
- Houston, TX · TIN 93-0870375
- Authorisation / referral
- PA2026370400 / 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 | $2,869.00 | $1,577.95 | — | — | Review |
| Totals | $2,869.00 | $1,577.95 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-775543
- 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-001140 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-20: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026370400 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Reference Lab (4399070182). | |
| 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: Pinecrest Reference Lab2025-12-20 15:36
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-04 01:20
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-04 11:14
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026370400_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-775543.pdf4 pages
Itemised statement totalling $2869.00 across 1 line.
- Medical recordrecords_PA-775543.pdf18 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 recommendationPended2026-10-21 14:05The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms. The current documentation does not support the medical necessity of the MRI. The claim is pended to verify if additional documentation can be provided to support the medical necessity of the MRI.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 17a7bdb4
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032124 | 2025-12-08 | Unity Medical Group | $2,231.00 | Needs review |
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). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms. The current documentation does not support the medical necessity of the MRI. The claim is pended to verify if additional documentation can be provided to support the medical necessity of the MRI.
- Verify if the clinical note supports the medical necessity of the MRI given the routine diagnosis.
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.