CLM-2026-022907
Lakeside Clinical Laboratories, Clinical Laboratory. Service 2025-11-26 at outpatient hospital (POS 22). Received 2026-01-02.
Member
Resolved through the identity graph
- Member
- Amanda Fisher
- Member ID
- UHC-11517-28
- Date of birth
- 1970-08-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417906
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-9920
- Coverage period
- 2023-11-01 to present
- Deductible
- $178.92 of $500.0036%
- Out-of-pocket maximum
- $679.08 of $1,500.0045%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4658545775
- Network
- In network
- Rendering NPI
- 4658545775
- Location
- Nashville, TN · TIN 46-3944413
- Authorisation / referral
- PA2025272082 / REF693991
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 | $2,835.00 | $1,559.25 | — | — | Review |
| Totals | $2,835.00 | $1,559.25 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-888988
- 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-000358 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-26: NAVIGATE-HMO (HMO), effective 2023-11-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025272082 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Clinical Laboratories (4658545775). | |
| 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: Lakeside Clinical Laboratories2025-11-26 16:26
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 system2026-01-02 00:38
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 letterPA2025272082_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-11-26 to 2026-02-24.
- Itemized billitemized_PA-888988.pdf4 pages
Itemised statement totalling $2835.00 across 1 line.
- Medical recordrecords_PA-888988.pdf20 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 14:05The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025272082) and is in-network. The clinical note [N1] and medical record [A3] document progressive neurological symptoms and failed conservative therapy over 8 weeks, which supports the medical necessity of the MRI. The claim is within the auto-adjudication ceiling and all required documentation is present. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · 6444bd37
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 (PA2025272082) and is in-network. The clinical note [N1] and medical record [A3] document progressive neurological symptoms and failed conservative therapy over 8 weeks, which supports the medical necessity of the MRI. The claim is within the auto-adjudication ceiling and all required documentation is present. Therefore, the claim is approved.
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.