CLM-2026-014279
Northgate Counseling Center, Behavioral Health. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-06-11.
Member
Resolved through the identity graph
- Member
- Justin Johnson
- Member ID
- UHC-07622-05
- Date of birth
- 2003-07-03
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-413902
- Relationship
- Child, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-7038
- Coverage period
- 2024-02-01 to 2026-01-16
- Deductible
- $198.37 of $500.0040%
- Out-of-pocket maximum
- $202.70 of $1,000.0020%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Counseling CenterBehavioral Health · taxonomy 103T00000X
- NPI
- 4860306727
- Network
- In network
- Rendering NPI
- 9651149624
- Location
- Austin, TX · TIN 78-2836028
- Authorisation / referral
- PA2026846384 / 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 | $2,939.00 | $1,616.45 | — | — | DeniedCO27 |
| Totals | $2,939.00 | $1,616.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-272119
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-034053 (verified, link confidence 0.96). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-06 is after coverage terminated on 2026-01-16. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026846384 on file for 70553. | |
| Provider network | Pass | In-network provider Northgate Counseling Center (4860306727). | |
| 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: Northgate Counseling Center2026-06-06 11:41
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-06-11 05:37
Attachments
Documents received with the claim
- Prior auth letterPA2026846384_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-06 to 2026-09-04.
- Itemized billitemized_PA-272119.pdf7 pages
Itemised statement totalling $2939.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-06-06 is after coverage terminated on 2026-01-16. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-031782 | 2026-05-14 | Pinecrest Diagnostic Imaging | $387.00 | Denied |
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.