CLM-2026-019496
Valley Medical Group, Family Medicine. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-01-13.
Member
Resolved through the identity graph
- Member
- Jack Austin
- Member ID
- UHC-01081-09
- Date of birth
- 1950-04-20
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-424621
- Relationship
- Self, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- N/A PPO group GRP-8020
- Coverage period
- 2023-01-01 to present
- Deductible
- $1,209.96 of $3,500.0035%
- Out-of-pocket maximum
- $3,166.16 of $7,000.0045%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 5938488512
- Network
- In network
- Rendering NPI
- 2038262145
- Location
- Tempe, AZ · TIN 76-2268417
- Authorisation / referral
- PA2025552826 / 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 | $3,106.00 | $1,708.30 | — | — | Review |
| Totals | $3,106.00 | $1,708.30 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-177751
- 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-002844 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-04: N/A (PPO), effective 2023-01-01. | |
| Timely filing | Pass | Received 9 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025552826 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Medical Group (5938488512). | |
| 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: Valley Medical Group2026-01-04 11:16
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 system2026-01-13 06:14
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 letterPA2025552826_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-04 to 2026-04-04.
- Itemized billitemized_PA-177751.pdf9 pages
Itemised statement totalling $3106.00 across 1 line.
- Medical recordrecords_PA-177751.pdf13 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 12:43 · edcbdc53
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027300 | 2026-02-16 | Heritage Physical Therapy | $154.00 | Denied |
| CLM-2026-015720 | 2025-11-30 | Northgate Medical Group | $310.00 | Approved |
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.