CLM-2026-024319
Northgate Cardiovascular Associates, Cardiology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Mariana Hill
- Member ID
- UHC-13011-56
- Date of birth
- 1943-09-18
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401649
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-2352
- Coverage period
- 2021-10-01 to present
- Deductible
- $1,012.88 of $3,500.0029%
- Out-of-pocket maximum
- $1,796.48 of $14,000.0013%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 2481567347
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- PA2026355182 / REF215216
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 | $2,527.00 | $1,389.85 | — | — | Review |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1,2 | $904.00 | $497.20 | — | — | Review |
| Totals | $3,431.00 | $1,887.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-241236
- 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-001392 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: NAVIGATE-HMO (HMO), effective 2021-10-01. | |
| 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 PA2026355182 on file for 70553. | |
| Provider network | Pass | In-network provider Northgate Cardiovascular Associates (5594465275). | |
| 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: Northgate Cardiovascular Associates2025-12-30 09:15
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 system2026-01-14 03:20
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 letterPA2026355182_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-241236.pdf7 pages
Itemised statement totalling $3431.00 across 2 lines.
- Medical recordrecords_PA-241236.pdf14 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.
- AI recommendationApproved2026-10-23 19:13The claim has passed all deterministic checks and the clinical note [N1] supports the medical necessity of the MRI brain with and without contrast (70553) due to progressive neurological symptoms and failed conservative therapy. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV] and the member is eligible [R-eligibility]. The billed amount is within the auto-adjudication ceiling [R-high_dollar].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:13 · 8d4cf8ec
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003329 | 2025-11-26 | Meadow Family Practice | $186.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim has passed all deterministic checks and the clinical note [N1] supports the medical necessity of the MRI brain with and without contrast (70553) due to progressive neurological symptoms and failed conservative therapy. The prior authorisation [A1] is valid and matches the service provided. The provider is in-network [PRV] and the member is eligible [R-eligibility]. The billed amount is within the auto-adjudication ceiling [R-high_dollar].
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.