CLM-2026-015825
Heritage Medical Group, Internal Medicine. Service 2025-12-24 at outpatient hospital (POS 22). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Joshua Schmidt
- Member ID
- UHC-68680-16
- Date of birth
- 1973-02-14
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-410041
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4045
- Coverage period
- 2023-02-01 to present
- Deductible
- $285.58 of $1,500.0019%
- Out-of-pocket maximum
- $491.56 of $4,500.0011%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 9350331127
- Network
- In network
- Rendering NPI
- 7942940801
- Location
- Denver, CO · TIN 85-4450273
- Authorisation / referral
- PA2026526983 / 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 | $2,177.00 | $1,197.35 | — | — | Review |
| Totals | $2,177.00 | $1,197.35 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-157607
- 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-003195 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-24: OPTIONS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026526983 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Medical Group (9350331127). | |
| 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: Heritage Medical Group2025-12-24 13:56
Patient seen for encounter for general adult medical examination without abnormal findings. 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 system2026-01-10 02:31
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-10 17:45
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026526983_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-24 to 2026-03-24.
- Itemized billitemized_PA-157607.pdf4 pages
Itemised statement totalling $2177.00 across 1 line.
- Medical recordrecords_PA-157607.pdf19 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 recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:42 · 1276c095
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
Notes document medical necessity.