CLM-2026-025943
Canyon Skin Care Associates, Dermatology. Service 2025-12-07 at outpatient hospital (POS 22). Received 2026-01-21.
Member
Resolved through the identity graph
- Member
- Samuel Gardner
- Member ID
- UHC-71837-12
- Date of birth
- 1940-08-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431703
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-1786
- Coverage period
- 2021-10-01 to present
- Deductible
- $293.43 of $2,500.0012%
- Out-of-pocket maximum
- $4,698.42 of $10,000.0047%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Skin Care AssociatesDermatology · taxonomy 207N00000X
- NPI
- 5664814501
- Network
- In network
- Rendering NPI
- 1416841363
- Location
- Nashville, TN · TIN 35-2130614
- Authorisation / referral
- PA2025330245 / 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 | $2,963.00 | $1,629.65 | — | — | Review |
| Totals | $2,963.00 | $1,629.65 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-421366
- 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-004364 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-07: UNKNOWN (PPO), effective 2021-10-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025330245 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Skin Care Associates (5664814501). | |
| 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: Canyon Skin Care Associates2025-12-07 11:28
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 system2026-01-21 02:39
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-21 16:12
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2025330245_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-07 to 2026-03-07.
- Itemized billitemized_PA-421366.pdf7 pages
Itemised statement totalling $2963.00 across 1 line.
- Medical recordrecords_PA-421366.pdf5 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-016982 | 2026-01-18 | Pinecrest Medical Group | $268.00 | 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.