CLM-2026-009416
Northgate Medical Group, Family Medicine. Service 2025-12-04 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Joseph Flores
- Member ID
- UHC-70640-04
- Date of birth
- 1958-02-10
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-426651
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3511
- Coverage period
- 2024-06-01 to present
- Deductible
- $50.68 of $1,500.003%
- Out-of-pocket maximum
- $2,132.34 of $6,000.0036%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6636200761
- Network
- In network
- Rendering NPI
- 9181126985
- Location
- Mesa, AZ · TIN 30-3649363
- Authorisation / referral
- PA2026961759 / 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 | $2,513.00 | $1,382.15 | — | — | Review |
| Totals | $2,513.00 | $1,382.15 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-556421
- 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-001278 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-04: UNKNOWN (PPO), effective 2024-06-01. | |
| Timely filing | Pass | Received 32 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026961759 on file for 70553. | |
| Provider network | Pass | In-network provider Northgate Medical Group (6636200761). | |
| 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: Northgate Medical Group2025-12-04 14:26
Patient seen for encounter for general adult medical examination without abnormal findings. 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 system2026-01-05 06:23
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-05 12:21
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026961759_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-04 to 2026-03-04.
- Itemized billitemized_PA-556421.pdf3 pages
Itemised statement totalling $2513.00 across 1 line.
- Medical recordrecords_PA-556421.pdf14 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.
- AI recommendationApproved2026-10-21 14:14The claim for an MRI brain with and without contrast (70553) is supported by the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [R-network], and the member is eligible [R-eligibility]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and the service is not bundled [R-ncci]. The claim is complete [R-completeness] and not a duplicate [R-duplicate]. The timely filing requirement is met [R-timely_filing], and the benefit limits are not exceeded [R-benefit_limit].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · 761f9e77
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023787 | 2026-09-12 | Heritage Imaging Center | $351.00 | Approved |
| CLM-2026-033812 | 2026-04-04 | Summit Community Hospital | $1,874.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for an MRI brain with and without contrast (70553) is supported by the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [R-network], and the member is eligible [R-eligibility]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and the service is not bundled [R-ncci]. The claim is complete [R-completeness] and not a duplicate [R-duplicate]. The timely filing requirement is met [R-timely_filing], and the benefit limits are not exceeded [R-benefit_limit].
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.