CLM-2026-026592
Riverside Clinical Laboratories, Clinical Laboratory. Service 2026-02-18 at outpatient hospital (POS 22). Received 2026-02-25.
Member
Resolved through the identity graph
- Member
- Billy Ryan
- Member ID
- UHC-08302-55
- Date of birth
- 1941-06-01
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-418253
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-1639
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,109.26 of $1,500.0074%
- Out-of-pocket maximum
- $1,485.84 of $6,000.0025%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 4514050481
- Network
- In network
- Rendering NPI
- 4514050481
- Location
- Tempe, AZ · TIN 12-2226671
- Authorisation / referral
- PA2025127171 / 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 | $2,640.00 | $1,452.00 | — | — | Review |
| Totals | $2,640.00 | $1,452.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-821434
- 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-015734 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-18: MEDICARE-ADV-B (MA), effective 2021-02-01. | |
| Timely filing | Pass | Received 7 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025127171 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Clinical Laboratories (4514050481). | |
| 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: Riverside Clinical Laboratories2026-02-18 09:28
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 system2026-02-25 02:36
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-02-25 15:04
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2025127171_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-02-18 to 2026-05-19.
- Itemized billitemized_PA-821434.pdf2 pages
Itemised statement totalling $2640.00 across 1 line.
- Medical recordrecords_PA-821434.pdf12 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
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.