CLM-2026-022823
Unity Medical Group, Internal Medicine. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Carl Rivera
- Member ID
- UHC-16910-17
- Date of birth
- 1980-12-03
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-420573
- Relationship
- Self, Eden Prairie, MN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-4324
- Coverage period
- 2025-07-01 to present
- Deductible
- $297.74 of $1,000.0030%
- Out-of-pocket maximum
- $1,022.86 of $3,000.0034%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupInternal Medicine · taxonomy 207R00000X
- NPI
- 1355996814
- Network
- In network
- Rendering NPI
- 5392105917
- Location
- Mesa, AZ · TIN 43-9161942
- Authorisation / referral
- PA2025616666 / 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 | $3,569.00 | $1,962.95 | — | — | Review |
| Totals | $3,569.00 | $1,962.95 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. N18.30 Chronic kidney disease, stage 3 unspecified
- Patient account
- PA-291073
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001724 (verified, link confidence 0.94). | |
| Eligibility | Pass | Active on 2025-12-22: CHOICE-PLUS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025616666 on file for 70553. | |
| Provider network | Pass | In-network provider Unity Medical Group (1355996814). | |
| 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 Medical Group2025-12-22 11:44
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. 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 system2026-01-06 06:04
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 letterPA2025616666_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-22 to 2026-03-22.
- Itemized billitemized_PA-291073.pdf3 pages
Itemised statement totalling $3569.00 across 1 line.
- Medical recordrecords_PA-291073.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 engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationApproved2026-10-21 14:15The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025616666) and is medically necessary as documented in the clinical notes (N1) and medical record (A3). The service was provided by an in-network provider (PRV) and the member was eligible at the time of service (COV). The billed amount is within the auto-adjudication ceiling (R-high_dollar) and the claim is complete (R-completeness). The clinical note supports the necessity of the imaging due to progressive neurological symptoms and failed conservative therapy over 8 weeks, which aligns with the payer policy for advanced imaging.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · eae6eb8e
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 (PA2025616666) and is medically necessary as documented in the clinical notes (N1) and medical record (A3). The service was provided by an in-network provider (PRV) and the member was eligible at the time of service (COV). The billed amount is within the auto-adjudication ceiling (R-high_dollar) and the claim is complete (R-completeness). The clinical note supports the necessity of the imaging due to progressive neurological symptoms and failed conservative therapy over 8 weeks, which aligns with the payer policy for advanced imaging.
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.