CLM-2026-013222
Sunrise Community Hospital, Emergency Medicine. Service 2026-07-16 at outpatient hospital (POS 22). Received 2026-08-07.
Member
Resolved through the identity graph
- Member
- Rachel Lopez
- Member ID
- UHC-36747-79
- Date of birth
- 1939-02-07
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-406637
- Relationship
- Self, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2859
- Coverage period
- 2022-02-01 to 2026-06-25
- Deductible
- $255.20 of $500.0051%
- Out-of-pocket maximum
- $27.67 of $1,000.003%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- Authorisation / referral
- PA2026187472 / 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 | $2,916.00 | $1,312.20 | — | — | DeniedCO27 |
| Totals | $2,916.00 | $1,312.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-171226
- 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-005973 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-16 is after coverage terminated on 2026-06-25. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026187472 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Sunrise Community Hospital2026-07-16 09:18
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-08-07 01:07
Attachments
Documents received with the claim
- Prior auth letterPA2026187472_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-16 to 2026-10-14.
- Itemized billitemized_PA-171226.pdf3 pages
Itemised statement totalling $2916.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-16 is after coverage terminated on 2026-06-25. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical 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
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.