CLM-2026-017211
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Bobby Gilbert
- Member ID
- UHC-19167-90
- Date of birth
- 1980-02-07
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-415359
- Relationship
- Spouse, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-2636
- Coverage period
- 2024-04-01 to present
- Deductible
- $60.86 of $2,500.002%
- Out-of-pocket maximum
- $1,293.96 of $5,000.0026%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 8920689386
- Network
- In network
- Rendering NPI
- 8920689386
- Location
- Mesa, AZ · TIN 50-3391688
- Authorisation / referral
- PA2025883499 / 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 | $2,180.00 | $1,199.00 | — | — | Review |
| Totals | $2,180.00 | $1,199.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-472524
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-000180 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-22: OPTIONS-PPO (PPO), effective 2024-04-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025883499 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Clinical Laboratories (8920689386). | |
| 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: Lakeside Clinical Laboratories2025-12-22 13:58
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 system2026-01-01 00:46
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
Attachments
Documents received with the claim
- Prior auth letterPA2025883499_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-22 to 2026-03-22.
- Itemized billitemized_PA-472524.pdf7 pages
Itemised statement totalling $2180.00 across 1 line.
- Medical recordrecords_PA-472524.pdf5 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 engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationApproved2026-10-21 14:05The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025883499) and clinical notes (N1) that document progressive neurological symptoms and failed conservative therapy over 8 weeks. The service is medically necessary to rule out a structural cause, as per the payer policy. The provider is in-network, and the claim is within the timely filing limit. The billed amount is below the auto-adjudication ceiling, and the member is eligible for the service. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 27a6da38
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007541 | 2026-04-30 | Sunrise Bone and Joint Center | $33,633.00 | Needs review |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025883499) and clinical notes (N1) that document progressive neurological symptoms and failed conservative therapy over 8 weeks. The service is medically necessary to rule out a structural cause, as per the payer policy. The provider is in-network, and the claim is within the timely filing limit. The billed amount is below the auto-adjudication ceiling, and the member is eligible for the service. Therefore, the claim is approved.
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.