CLM-2026-024777
Meadow Regional Medical Center, Emergency Medicine. Service 2025-12-14 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Amanda Mendoza
- Member ID
- UHC-89922-24
- Date of birth
- 1941-02-24
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-416003
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5060
- Coverage period
- 2024-07-01 to present
- Deductible
- $493.35 of $1,500.0033%
- Out-of-pocket maximum
- $1,783.15 of $4,500.0040%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Meadow Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 1905050427
- Network
- In network
- Rendering NPI
- 1905050427
- Location
- Dallas, TX · TIN 71-2312931
- Authorisation / referral
- PA2025694099 / 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 | $3,089.00 | $1,698.95 | — | — | Review |
| Totals | $3,089.00 | $1,698.95 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-648350
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-001584 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-14: MEDICARE-ADV-B (MA), effective 2024-07-01. | |
| Timely filing | Pass | Received 22 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025694099 on file for 70553. | |
| Provider network | Pass | In-network provider Meadow Regional Medical Center (1905050427). | |
| 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: Meadow Regional Medical Center2025-12-14 13:39
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-05 05:02
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 letterPA2025694099_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-14 to 2026-03-14.
- Itemized billitemized_PA-648350.pdf4 pages
Itemised statement totalling $3089.00 across 1 line.
- Medical recordrecords_PA-648350.pdf5 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:14The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings. The clinical note confirms this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · 39952284
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011766 | 2025-11-25 | Mesa Internal Medicine Associates | $319.00 | Approved |
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings. The clinical note confirms this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy.
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.