CLM-2026-015238
Evergreen Orthopedic Specialists, Orthopedic Surgery. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-08-14.
Member
Resolved through the identity graph
- Member
- Yuki Jackson
- Member ID
- none on golden record
- Date of birth
- 1948-06-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412956
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Evergreen Orthopedic SpecialistsOrthopedic Surgery · taxonomy 207X00000X
- NPI
- 4479500462
- Network
- In network
- Rendering NPI
- 6524622589
- Location
- Tempe, AZ · TIN 82-7144175
- Authorisation / referral
- PA2025103140 / 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 | $2,125.00 | $1,168.75 | — | — | PendedN30 |
| Totals | $2,125.00 | $1,168.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-631082
- 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-041483 (provisional, link confidence 1.00). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 36 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025103140 on file for 70553. | |
| Provider network | Pass | In-network provider Evergreen Orthopedic Specialists (4479500462). | |
| 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: Evergreen Orthopedic Specialists2026-07-09 18:25
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-08-14 00:12
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-14 08:29
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025103140_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-09 to 2026-10-07.
- Itemized billitemized_PA-631082.pdf8 pages
Itemised statement totalling $2125.00 across 1 line.
- Medical recordrecords_PA-631082.pdf19 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Eligibility: No coverage segment found for the member ID on this claim. 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
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.