CLM-2026-024300
Valley Family Practice, Family Medicine. Service 2026-07-27 at outpatient hospital (POS 22). Received 2026-08-16.
Member
Resolved through the identity graph
- Member
- Bobby Harris
- Member ID
- UHC-29409-54
- Date of birth
- 1947-09-21
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-417562
- Relationship
- Child, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4646
- Coverage period
- 2025-02-01 to present
- Deductible
- $1,063.30 of $2,500.0043%
- Out-of-pocket maximum
- $1,207.11 of $7,500.0016%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 0 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 3411841638
- Network
- In network
- Rendering NPI
- 7422555699
- Location
- Houston, TX · TIN 34-3279519
- Authorisation / referral
- PA2025900336 / 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 | $3,225.00 | $1,773.75 | — | — | Review |
| Totals | $3,225.00 | $1,773.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-342081
- 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-022516 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-27: MEDICARE-ADV-A (MA), effective 2025-02-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025900336 on file for 70553. | |
| Provider network | Pass | In-network provider Valley Family Practice (3411841638). | |
| 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: Valley Family Practice2026-07-27 13:34
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-08-16 04:59
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 letterPA2025900336_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-27 to 2026-10-25.
- Itemized billitemized_PA-342081.pdf8 pages
Itemised statement totalling $3225.00 across 1 line.
- Medical recordrecords_PA-342081.pdf8 pages
Clinic notes for a routine annual visit; no symptoms documented.
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-2026-002087 | 2026-03-25 | Unity Imaging Center | $4,908.00 | 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
Routine diagnosis does not support advanced imaging.