CLM-2026-026838
Mesa Clinical Laboratories, Clinical Laboratory. Service 2026-04-07 at outpatient hospital (POS 22). Received 2026-04-12.
Member
Resolved through the identity graph
- Member
- Maria Dunn
- Member ID
- UHC-04782-32
- Date of birth
- 1964-08-17
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404134
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1502
- Coverage period
- 2023-12-01 to 2026-01-19
- Deductible
- $855.35 of $1,500.0057%
- Out-of-pocket maximum
- $2,685.75 of $6,000.0045%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Clinical LaboratoriesClinical Laboratory · taxonomy 291U00000X
- NPI
- 2023964945
- Network
- Out of network
- Rendering NPI
- 2023964945
- Location
- Atlanta, GA · TIN 12-9444799
- Authorisation / referral
- PA2025717050 / 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 | $3,421.00 | $1,539.45 | — | — | DeniedCO27 |
| Totals | $3,421.00 | $1,539.45 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-690295
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 3 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-025493 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-04-07 is after coverage terminated on 2026-01-19. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 5 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025717050 on file for 70553. | |
| Provider network | Note | Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. | |
| 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: Mesa Clinical Laboratories2026-04-07 13:47
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-04-12 01:01
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-12 14:16
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Prior auth letterPA2025717050_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-04-07 to 2026-07-06.
- Itemized billitemized_PA-690295.pdf2 pages
Itemised statement totalling $3421.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-04-07 is after coverage terminated on 2026-01-19. Provider network: Out-of-network provider; priced at the out-of-network allowance, balance billing may apply. Medical 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-2026-006458 | 2026-06-26 | Sunrise Imaging Center | $1,607.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.