CLM-2026-011954
Lakeside Skin Care Associates, Dermatology. Service 2026-01-02 at outpatient hospital (POS 22). Received 2026-01-08.
Member
Resolved through the identity graph
- Member
- Diana Carroll
- Member ID
- UHC-85368-85
- Date of birth
- 1990-11-07
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-428428
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7889
- Coverage period
- 2021-05-01 to present
- Deductible
- $54.46 of $2,500.002%
- Out-of-pocket maximum
- $1,148.34 of $7,500.0015%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 7921872736
- Network
- In network
- Rendering NPI
- 1623429952
- Location
- Tempe, AZ · TIN 98-6599721
- Authorisation / referral
- PA2025588275 / 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 | $2,654.00 | $1,459.70 | — | — | Review |
| Totals | $2,654.00 | $1,459.70 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-764078
- 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-002515 (provisional, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-02: NAVIGATE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025588275 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Skin Care Associates (7921872736). | |
| 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 Skin Care Associates2026-01-02 13:09
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-01-08 04:06
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-08 11:41
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2025588275_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-02 to 2026-04-02.
- Itemized billitemized_PA-764078.pdf8 pages
Itemised statement totalling $2654.00 across 1 line.
- Medical recordrecords_PA-764078.pdf7 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 14:15The claim for an MRI brain with and without contrast (70553) is supported by clinical notes [N1] and medical records [A3] that document 8 weeks of failed conservative therapy and progressive neurological symptoms, which justifies the medical necessity of the imaging. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV], and the member is eligible [IDN, COV]. The claim is within the auto-adjudication ceiling [R-high_dollar] and is complete [R-completeness]. However, the billed amount exceeds $15,000.00, requiring human sign-off [requires_human=True].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · c30a4482
Other claims for this member
Same resolved identity
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 clinical notes [N1] and medical records [A3] that document 8 weeks of failed conservative therapy and progressive neurological symptoms, which justifies the medical necessity of the imaging. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV], and the member is eligible [IDN, COV]. The claim is within the auto-adjudication ceiling [R-high_dollar] and is complete [R-completeness]. However, the billed amount exceeds $15,000.00, requiring human sign-off [requires_human=True].
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.