CLM-2026-022002
Heritage Community Hospital, Emergency Medicine. Service 2025-12-05 at outpatient hospital (POS 22). Received 2026-01-15.
Member
Resolved through the identity graph
- Member
- Lori Montgomery
- Member ID
- UHC-72169-83
- Date of birth
- 2005-10-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420611
- Relationship
- Spouse, Dallas, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2500
- Coverage period
- 2021-07-01 to present
- Deductible
- $902.68 of $1,500.0060%
- Out-of-pocket maximum
- $1,641.56 of $4,500.0036%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2102151364
- Network
- In network
- Rendering NPI
- 2102151364
- Location
- Tampa, FL · TIN 69-1549407
- Authorisation / referral
- PA2025623075 / 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 | $2,980.00 | $1,639.00 | — | — | Review |
| Totals | $2,980.00 | $1,639.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-758660
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-004755 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-05: SELECT-EPO (EPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 41 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025623075 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Community Hospital (2102151364). | |
| 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: Heritage Community Hospital2025-12-05 14:20
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 system2026-01-15 02:21
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 letterPA2025623075_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-05 to 2026-03-05.
- Itemized billitemized_PA-758660.pdf3 pages
Itemised statement totalling $2980.00 across 1 line.
- Medical recordrecords_PA-758660.pdf4 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.
- AI recommendationApproved2026-10-23 19:13The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025623075) and is medically necessary as documented in the clinical note (N1) and medical record (A3). The provider is in-network, and the claim is within the timely filing limit. The billed amount is above $15,000.00, requiring human sign-off. The claim is approved with a confidence of 0.95.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:13 · 4b2059d8
- AI recommendation validatedClaims rules engine2026-10-23 19:13 · 8112e053
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025623075) and is medically necessary as documented in the clinical note (N1) and medical record (A3). The provider is in-network, and the claim is within the timely filing limit. The billed amount is above $15,000.00, requiring human sign-off. The claim is approved with a confidence of 0.95.
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.