CLM-2026-020085
Sunrise Family Practice, Family Medicine. Service 2026-09-01 at outpatient hospital (POS 22). Received 2026-10-09.
Member
Resolved through the identity graph
- Member
- Catherine Hart
- Member ID
- UHC-18151-19
- Date of birth
- 1963-09-20
- Identity
- Verified6 records, confidence 0.96
- Claim record
- CLMCLM-419382
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3663
- Coverage period
- 2025-04-01 to present
- Deductible
- $1,927.23 of $2,500.0077%
- Out-of-pocket maximum
- $4,611.23 of $10,000.0046%
- Copays
- office $25.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3793775529
- Network
- In network
- Rendering NPI
- 8060014528
- Location
- Miami, FL · TIN 77-9706037
- Authorisation / referral
- PA2025253142 / 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 | $2,291.00 | $1,260.05 | — | — | Review |
| Totals | $2,291.00 | $1,260.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-973559
- 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-008446 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-09-01: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 38 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025253142 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Family Practice (3793775529). | |
| 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: Sunrise Family Practice2026-09-01 15:56
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. 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 system2026-10-09 00:01
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 letterPA2025253142_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-09-01 to 2026-11-30.
- Itemized billitemized_PA-973559.pdf8 pages
Itemised statement totalling $2291.00 across 1 line.
- Medical recordrecords_PA-973559.pdf11 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-018350 | 2026-06-15 | Northgate Reference Lab | $72.00 | Approved |
| CLM-2026-024328 | 2026-05-14 | Desert Reference Lab | $36.00 | Approved |
| CLM-2026-015118 | 2026-04-23 | Northgate Primary Care Associates | $23.00 | Approved |
| CLM-2026-034350 | 2025-12-14 | Sunrise Community Hospital | $1,298.00 | Needs review |
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.