CLM-2026-020266
Sunrise Community Hospital, Emergency Medicine. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Sarah Cruz
- Member ID
- UHC-84264-42
- Date of birth
- 2002-05-22
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-402526
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6589
- Coverage period
- 2022-12-01 to present
- Deductible
- $149.13 of $1,000.0015%
- Out-of-pocket maximum
- $1,763.63 of $4,000.0044%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2411187117
- Network
- Out of network
- Rendering NPI
- 2411187117
- Location
- Tempe, AZ · TIN 19-3902018
- Authorisation / referral
- PA2026824074 / 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 | $2,282.00 | $1,026.90 | — | — | PendedIDQ |
| Totals | $2,282.00 | $1,026.90 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-969780
- Frequency code
- 1 (original)
- Accident
- Yes
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000640; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-12-29: UNKNOWN (PPO), effective 2022-12-01. | |
| 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 PA2026824074 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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 Community Hospital2025-12-29 12:02
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-07 06:50
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 letterPA2026824074_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-969780.pdf8 pages
Itemised statement totalling $2282.00 across 1 line.
- Medical recordrecords_PA-969780.pdf16 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-000640; payment withheld until the identity is confirmed. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
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
Routine diagnosis does not support advanced imaging.