CLM-2026-021659
Meadow Internal Medicine Associates, Internal Medicine. Service 2026-07-15 at outpatient hospital (POS 22). Received 2026-07-25.
Member
Resolved through the identity graph
- Member
- Mary Patel
- Member ID
- UHC-02629-56
- Date of birth
- 1985-08-12
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-423487
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3482
- Coverage period
- 2021-05-01 to present
- Deductible
- $122.70 of $1,000.0012%
- Out-of-pocket maximum
- $694.80 of $2,000.0035%
- Copays
- office $30.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 1151313396
- Network
- In network
- Rendering NPI
- 3675987549
- Location
- Phoenix, AZ · TIN 41-0387297
- Authorisation / referral
- PA2025829202 / REF709752
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 | $3,004.00 | $1,652.20 | — | — | Review |
| Totals | $3,004.00 | $1,652.20 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-241555
- 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-004396 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-15: CORE-HMO (HMO), effective 2021-05-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025829202 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Internal Medicine Associates (1151313396). | |
| 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 Internal Medicine Associates2026-07-15 09:09
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 system2026-07-25 01:46
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-25 13:12
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025829202_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-15 to 2026-10-13.
- Itemized billitemized_PA-241555.pdf4 pages
Itemised statement totalling $3004.00 across 1 line.
- Medical recordrecords_PA-241555.pdf14 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-2026-022485 | 2026-07-03 | Canyon Community Hospital | $2,847.00 | Needs review |
| CLM-2026-029690 | 2026-06-01 | Unity Diagnostic Imaging | $2,329.00 | Needs review |
| CLM-2026-029689 | 2026-06-01 | Evergreen Diagnostic Imaging | $2,329.00 | 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.