CLM-2026-024051
Lakeside Reference Lab, Clinical Laboratory. Service 2026-07-12 at outpatient hospital (POS 22). Received 2026-08-21.
Member
Resolved through the identity graph
- Member
- Olivia Fox
- Member ID
- UHC-47212-39
- Date of birth
- 1976-01-11
- Identity
- Verified6 records, confidence 0.97
- Claim record
- CLMCLM-404153
- Relationship
- Self, Austin, TX
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-0112
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,188.43 of $1,500.0079%
- Out-of-pocket maximum
- $1,293.44 of $4,500.0029%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Reference LabClinical Laboratory · taxonomy 291U00000X
- NPI
- 8593662793
- Network
- In network
- Rendering NPI
- 8593662793
- Location
- Austin, TX · TIN 19-8347023
- Authorisation / referral
- PA2026060909 / 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 | $1,823.00 | $1,002.65 | — | — | Review |
| Totals | $1,823.00 | $1,002.65 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. N39.0 Urinary tract infection, site not specified
- Patient account
- PA-665677
- 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-002821 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-07-12: - (PPO), effective 2021-02-01. | |
| Timely filing | Pass | Received 40 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026060909 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Reference Lab (8593662793). | |
| 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 Reference Lab2026-07-12 17:55
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 system2026-08-21 03:12
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 15:47
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026060909_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-12 to 2026-10-10.
- Itemized billitemized_PA-665677.pdf8 pages
Itemised statement totalling $1823.00 across 1 line.
- Medical recordrecords_PA-665677.pdf7 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-002755 | 2026-05-19 | Sunrise Digestive Health Center | $3,767.00 | Approved |
| CLM-2026-012693 | 2026-05-13 | Pinecrest Bone and Joint Center | $220.00 | Approved |
| CLM-2026-023401 | 2025-12-13 | Lakeside Medical Group | $586.00 | 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.