CLM-2026-026357
Summit Cardiovascular Associates, Cardiology. Service 2025-12-17 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Grace Valdez
- Member ID
- UHC-35478-16
- Date of birth
- 2002-08-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401674
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4203
- Coverage period
- 2023-01-01 to present
- Deductible
- $529.14 of $1,000.0053%
- Out-of-pocket maximum
- $39.97 of $2,000.002%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 6938517813
- Location
- Houston, TX · TIN 53-6389420
- Authorisation / referral
- PA2026685543 / 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 | $3,501.00 | $1,925.55 | — | — | Review |
| Totals | $3,501.00 | $1,925.55 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-642899
- Frequency code
- 1 (original)
- Accident
- No
- 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-001677 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-17: OPTIONS-PPO (PPO), effective 2023-01-01. | |
| 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 PA2026685543 on file for 70553. | |
| Provider network | Pass | In-network provider Summit Cardiovascular Associates (5138686964). | |
| 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: Summit Cardiovascular Associates2025-12-17 18:37
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 system2026-01-06 03:39
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-01-06 17:16
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026685543_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-17 to 2026-03-17.
- Itemized billitemized_PA-642899.pdf9 pages
Itemised statement totalling $3501.00 across 1 line.
- Medical recordrecords_PA-642899.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 engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:15The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not support medical necessity [N1]. The policy requires documentation of failed conservative treatment or red-flag symptoms for advanced imaging with a routine examination diagnosis, which is not present in this case [R-clinical_edit]. Therefore, the service is not medically necessary per payer policy.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · adc1d9c9
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029864 | 2026-05-27 | Northgate Internal Medicine Associates | $201.00 | 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) and the clinical note does not support medical necessity [N1]. The policy requires documentation of failed conservative treatment or red-flag symptoms for advanced imaging with a routine examination diagnosis, which is not present in this case [R-clinical_edit]. 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.