CLM-2026-012064
Lakeside Internal Medicine Associates, Internal Medicine. Service 2025-12-10 at outpatient hospital (POS 22). Received 2026-01-17.
Member
Resolved through the identity graph
- Member
- Adam Robinson
- Member ID
- UHC-30142-97
- Date of birth
- 1941-11-07
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-430755
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1878
- Coverage period
- 2025-11-01 to present
- Deductible
- $3,084.91 of $3,500.0088%
- Out-of-pocket maximum
- $106.98 of $7,000.002%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 8566398227
- Network
- In network
- Rendering NPI
- 3060592862
- Location
- Denver, CO · TIN 22-9016721
- Authorisation / referral
- PA2026120026 / REF483821
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 | $3,124.00 | $1,718.20 | — | — | Review |
| Totals | $3,124.00 | $1,718.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-233012
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005134 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-10: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026120026 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Internal Medicine Associates (8566398227). | |
| 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 Internal Medicine Associates2025-12-10 16:39
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 system2026-01-17 06:35
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-01-17 08:20
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026120026_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-10 to 2026-03-10.
- Itemized billitemized_PA-233012.pdf8 pages
Itemised statement totalling $3124.00 across 1 line.
- Medical recordrecords_PA-233012.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 engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationApproved2026-10-23 19:14The 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 provider is in-network [PRV], and the prior authorisation [A1] is valid and matches the service provided. The claim is within the timely filing limit [R-timely_filing] and does not exceed the auto-adjudication ceiling [R-high_dollar]. All required documentation is present [R-completeness], and there are no bundling conflicts [R-ncci] or benefit limits [R-benefit_limit] that would prevent payment.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:14 · 5dca19fb
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 provider is in-network [PRV], and the prior authorisation [A1] is valid and matches the service provided. The claim is within the timely filing limit [R-timely_filing] and does not exceed the auto-adjudication ceiling [R-high_dollar]. All required documentation is present [R-completeness], and there are no bundling conflicts [R-ncci] or benefit limits [R-benefit_limit] that would prevent payment.
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.