CLM-2026-022027
Unity Primary Care Associates, Family Medicine. Service 2026-02-22 at outpatient hospital (POS 22). Received 2026-03-08.
Member
Resolved through the identity graph
- Member
- Christian Lopez
- Member ID
- UHC-33964-60
- Date of birth
- 1953-01-23
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-420293
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-6931
- Coverage period
- 2023-06-01 to 2026-01-10
- Deductible
- $358.09 of $500.0072%
- Out-of-pocket maximum
- $472.49 of $1,500.0031%
- Copays
- office $40.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 3512889619
- Network
- In network
- Rendering NPI
- 6008620620
- Location
- Houston, TX · TIN 72-6037041
- Authorisation / referral
- PA2026886208 / 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 | $3,387.00 | $1,862.85 | — | — | DeniedCO27 |
| Totals | $3,387.00 | $1,862.85 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-626759
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-016854 (verified, link confidence 0.97). | |
| Eligibility | Fail | CO27 | Date of service 2026-02-22 is after coverage terminated on 2026-01-10. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026886208 on file for 70553. | |
| Provider network | Pass | In-network provider Unity Primary Care Associates (3512889619). | |
| 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 Associates2026-02-22 15:18
Patient seen for encounter for general adult medical examination without abnormal findings.
- SystemSystem: Claims system2026-03-08 03:58
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-03-08 13:09
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026886208_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-22 to 2026-05-23.
- Itemized billitemized_PA-626759.pdf6 pages
Itemised statement totalling $3387.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-02-22 is after coverage terminated on 2026-01-10. 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
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.