CLM-2026-012834
Riverside Primary Care Associates, Family Medicine. Service 2026-05-29 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Christina Stone
- Member ID
- UHC-45212-97
- Date of birth
- 1983-04-02
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-417017
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-4231
- Coverage period
- 2021-07-01 to present
- Deductible
- $201.78 of $500.0040%
- Out-of-pocket maximum
- $595.87 of $1,500.0040%
- Copays
- office $25.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3508653433
- Network
- In network
- Rendering NPI
- 7290910323
- Location
- Nashville, TN · TIN 89-3003257
- Authorisation / referral
- PA2025129733 / 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 | $3,226.00 | $1,774.30 | — | — | Review |
| Totals | $3,226.00 | $1,774.30 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-697666
- 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-016931 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-29: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025129733 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Primary Care Associates (3508653433). | |
| 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: Riverside Primary Care Associates2026-05-29 10:59
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-06-27 02:25
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-06-27 10:02
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025129733_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-05-29 to 2026-08-27.
- Itemized billitemized_PA-697666.pdf7 pages
Itemised statement totalling $3226.00 across 1 line.
- Medical recordrecords_PA-697666.pdf16 pages
Clinic notes for a routine annual visit; no symptoms documented.
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.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
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
Routine diagnosis does not support advanced imaging.