CLM-2026-011863
Desert Medical Group, Internal Medicine. Service 2025-12-23 at outpatient hospital (POS 22). Received 2026-01-03.
Member
Resolved through the identity graph
- Member
- Yuki Herrera
- Member ID
- UHC-52366-24
- Date of birth
- 1996-01-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-402664
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6922
- Coverage period
- 2024-01-01 to present
- Deductible
- $699.88 of $1,500.0047%
- Out-of-pocket maximum
- $660.47 of $3,000.0022%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 4556045621
- Network
- In network
- Rendering NPI
- 4364663623
- Location
- Scottsdale, AZ · TIN 56-2756422
- Authorisation / referral
- PA2025535383 / 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 | $3,554.00 | $1,954.70 | — | — | Review |
| Totals | $3,554.00 | $1,954.70 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-497006
- 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-000768 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-23: CHOICE-PLUS-PPO (PPO), effective 2024-01-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025535383 on file for 70553. | |
| Provider network | Pass | In-network provider Desert Medical Group (4556045621). | |
| 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: Desert Medical Group2025-12-23 16:43
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. 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 system2026-01-03 02:20
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 letterPA2025535383_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-23 to 2026-03-23.
- Itemized billitemized_PA-497006.pdf3 pages
Itemised statement totalling $3554.00 across 1 line.
- Medical recordrecords_PA-497006.pdf6 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 14:05The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation [A1] and is medically necessary as documented in the clinical notes [N1] and medical record [A3]. The service was provided by an in-network provider [PRV], and the member is eligible for coverage [COV]. The claim is within the timely filing limit [R-timely_filing] and does not have any bundling conflicts [R-ncci]. The billed amount is within the auto-adjudication ceiling [R-high_dollar]. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 8d967dd1
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026698 | 2026-07-04 | Summit Regional Medical Center | $5,036.00 | Approved |
| CLM-2026-015788 | 2026-03-20 | Northgate Internal Medicine Associates | $557.00 | Approved |
| CLM-2026-009298 | 2026-02-18 | Sunrise Community Hospital | $2,000.00 | 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 a prior authorisation [A1] and is medically necessary as documented in the clinical notes [N1] and medical record [A3]. The service was provided by an in-network provider [PRV], and the member is eligible for coverage [COV]. The claim is within the timely filing limit [R-timely_filing] and does not have any bundling conflicts [R-ncci]. The billed amount is within the auto-adjudication ceiling [R-high_dollar]. Therefore, the claim is approved.
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.