CLM-2026-023994
Harbor Medical Group, Family Medicine. Service 2026-07-22 at outpatient hospital (POS 22). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Jesse Bennett
- Member ID
- UHC-57219-23
- Date of birth
- 1940-12-16
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-431463
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group GRP-2611
- Coverage period
- 2021-02-01 to present
- Deductible
- $886.24 of $1,000.0089%
- Out-of-pocket maximum
- $761.62 of $2,000.0038%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8631526927
- Network
- In network
- Rendering NPI
- 7916953897
- Location
- Los Angeles, CA · TIN 48-2346295
- Authorisation / referral
- PA2026256913 / 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 | $2,229.00 | $1,225.95 | — | — | Review |
| Totals | $2,229.00 | $1,225.95 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. J06.9 Acute upper respiratory infection, unspecified
- Patient account
- PA-609445
- 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-012984 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-22: NULL (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026256913 on file for 70553. | |
| Provider network | Pass | In-network provider Harbor Medical Group (8631526927). | |
| 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: Harbor Medical Group2026-07-22 09:03
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 system2026-08-21 02:05
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-08-21 10:34
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026256913_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-22 to 2026-10-20.
- Itemized billitemized_PA-609445.pdf6 pages
Itemised statement totalling $2229.00 across 1 line.
- Medical recordrecords_PA-609445.pdf21 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-2026-009602 | 2026-08-03 | Valley Medical Group | $158.00 | Approved |
| CLM-2026-011676 | 2026-02-22 | Meadow Heart Institute | $6,790.00 | Needs review |
| CLM-2026-034482 | 2026-01-14 | Desert Diagnostic Imaging | $3,419.00 | Needs review |
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.