CLM-2026-022525
Heritage Behavioral Health, Behavioral Health. Service 2026-01-25 at outpatient hospital (POS 22). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Debra Aguilar
- Member ID
- UHC-12963-51
- Date of birth
- 1995-07-07
- Identity
- Verified5 records, confidence 0.97
- Claim record
- CLMCLM-432373
- Relationship
- Child, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3121
- Coverage period
- 2024-04-01 to present
- Deductible
- $316.33 of $1,000.0032%
- Out-of-pocket maximum
- $371.45 of $4,000.009%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 1 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 8719330382
- Location
- Minneapolis, MN · TIN 71-8171673
- Authorisation / referral
- PA2025956490 / REF240960
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 | $3,577.00 | $1,967.35 | — | — | Review |
| Totals | $3,577.00 | $1,967.35 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. F90.2 ADHD, combined type
- Patient account
- PA-755398
- 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-012389 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-01-25: CORE-HMO (HMO), effective 2024-04-01. | |
| Timely filing | Pass | Received 31 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025956490 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Behavioral Health (3499047843). | |
| 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 Behavioral Health2026-01-25 10:32
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-02-25 04:02
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-02-25 17:06
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025956490_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-25 to 2026-04-25.
- Itemized billitemized_PA-755398.pdf6 pages
Itemised statement totalling $3577.00 across 1 line.
- Medical recordrecords_PA-755398.pdf9 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-2026-025780 | 2026-06-26 | Desert Reference Lab | $118.00 | Approved |
| CLM-2026-004854 | 2026-06-19 | Riverside Clinical Laboratories | $110.00 | Needs review |
| CLM-2026-020656 | 2026-01-19 | Mesa Family Practice | $312.00 | Denied |
| CLM-2026-020655 | 2026-01-19 | Mesa Family Practice | $312.00 | 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.