CLM-2026-019886
Meadow Medical Group, Family Medicine. Service 2026-03-27 at outpatient hospital (POS 22). Received 2026-05-11.
Member
Resolved through the identity graph
- Member
- Margaret Bryant
- Member ID
- UHC-57103-48
- Date of birth
- 1978-09-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419474
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7627
- Coverage period
- 2025-08-01 to present
- Deductible
- $142.20 of $500.0028%
- Out-of-pocket maximum
- $326.63 of $2,000.0016%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7358617562
- Network
- In network
- Rendering NPI
- 4352625501
- Location
- Tempe, AZ · TIN 28-5097821
- Authorisation / referral
- PA2026580919 / 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 | $1,883.00 | $1,035.65 | — | — | Review |
| Totals | $1,883.00 | $1,035.65 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-509631
- 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-017395 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-27: NAVIGATE-HMO (HMO), effective 2025-08-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026580919 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Medical Group (7358617562). | |
| 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: Meadow Medical Group2026-03-27 14:25
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 system2026-05-11 01:36
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-05-11 10:05
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2026580919_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-27 to 2026-06-25.
- Itemized billitemized_PA-509631.pdf8 pages
Itemised statement totalling $1883.00 across 1 line.
- Medical recordrecords_PA-509631.pdf22 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017090 | 2026-03-17 | Pinecrest Medical Group | $188.00 | Denied |
| CLM-2026-015003 | 2026-06-01 | Mesa Clinical Laboratories | $145.00 | Approved |
| CLM-2026-020874 | 2026-01-25 | Pinecrest Physical Therapy | $525.00 | 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.