CLM-2026-025202
Evergreen GI Associates, Gastroenterology. Service 2026-07-29 at outpatient hospital (POS 22). Received 2026-08-13.
Member
Resolved through the identity graph
- Member
- Alice Herrera
- Member ID
- none on golden record
- Date of birth
- 1980-06-25
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-418739
- Relationship
- Self, Tucson, AZ
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Evergreen GI AssociatesGastroenterology · taxonomy 207RG0100X
- NPI
- 1347472536
- Network
- In network
- Rendering NPI
- 1180604419
- Location
- Mesa, AZ · TIN 73-5641725
- Authorisation / referral
- PA2026982401 / 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 | $2,818.00 | $1,549.90 | — | — | PendedN30 |
| 2 | 88305 rev 0310 | Surgical pathology, level IV | — | 1 | 1,2 | $230.00 | $126.50 | — | — | PendedN30 |
| Totals | $3,048.00 | $1,676.40 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R10.13 Epigastric pain
- Patient account
- PA-921656
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-032240 (verified, link confidence 0.99). | |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| 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 PA2026982401 on file for 70553. | |
| Provider network | Pass | In-network provider Evergreen GI Associates (1347472536). | |
| 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: Evergreen GI Associates2026-07-29 16:06
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 system2026-08-13 00:37
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 letterPA2026982401_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-29 to 2026-10-27.
- Itemized billitemized_PA-921656.pdf7 pages
Itemised statement totalling $3048.00 across 2 lines.
- Medical recordrecords_PA-921656.pdf22 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Eligibility: No coverage segment found for the member ID on this claim. Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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.