CLM-2026-020373
Unity Primary Care Associates, Family Medicine. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-07-14.
Member
Resolved through the identity graph
- Member
- Patrick Fisher
- Member ID
- UHC-27825-83
- Date of birth
- 1985-08-03
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-415986
- Relationship
- Spouse, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7287
- Coverage period
- 2021-10-01 to 2026-04-23
- Deductible
- $683.28 of $3,500.0020%
- Out-of-pocket maximum
- $4,235.75 of $14,000.0030%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3636526220
- Network
- Out of network
- Rendering NPI
- 6975510820
- Location
- Charlotte, NC · TIN 92-2641302
- Authorisation / referral
- PA2025302487 / 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 | $2,840.00 | $1,278.00 | — | — | DeniedCO27 |
| Totals | $2,840.00 | $1,278.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- 3. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-349452
- Frequency code
- 1 (original)
- Accident
- No
- 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 | Pass | Attached to MBR-008563 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-12 is after coverage terminated on 2026-04-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 2 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025302487 on file for 70553. | |
| Provider network | Fail | CO204 | Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit. Service not covered under the member's plan |
| 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: Unity Primary Care Associates2026-07-12 18:38
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-14 06:03
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-07-14 08:30
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025302487_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-12 to 2026-10-10.
- Itemized billitemized_PA-349452.pdf3 pages
Itemised statement totalling $2840.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-12 is after coverage terminated on 2026-04-23. Provider network: Billing provider 3636526220 is out of network and the HMO plan has no out-of-network benefit. Medical 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-2026-020014 | 2026-08-11 | Harbor Family Practice | $29.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.