CLM-2026-010639
Lakeside Behavioral Health, Behavioral Health. Service 2026-05-03 at outpatient hospital (POS 22). Received 2026-05-17.
Member
Resolved through the identity graph
- Member
- Olivia Pena
- Member ID
- UHC-64907-39
- Date of birth
- 1962-11-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412406
- Relationship
- Spouse, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-8168
- Coverage period
- 2022-09-01 to 2026-01-09
- Deductible
- $2,693.86 of $3,500.0077%
- Out-of-pocket maximum
- $2,078.88 of $10,500.0020%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 2763853613
- Network
- Out of network
- Rendering NPI
- 1078011792
- Location
- Austin, TX · TIN 90-0644488
- Authorisation / referral
- PA2026356551 / REF442878
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 | $2,748.00 | $1,236.60 | — | — | DeniedCO27 |
| Totals | $2,748.00 | $1,236.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-906982
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-026987 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-05-03 is after coverage terminated on 2026-01-09. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026356551 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 2763853613 is out of network and the HMO 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: Lakeside Behavioral Health2026-05-03 13:45
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-05-17 05:13
Attachments
Documents received with the claim
- Prior auth letterPA2026356551_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-03 to 2026-08-01.
- Itemized billitemized_PA-906982.pdf2 pages
Itemised statement totalling $2748.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-05-03 is after coverage terminated on 2026-01-09. Provider network: Billing provider 2763853613 is out of network and the HMO 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033717 | 2026-04-06 | Summit Family Practice | $514.00 | Denied |
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
Service after coverage termination.