CLM-2026-026874
Riverside Community Hospital, Emergency Medicine. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- James Shaw
- Member ID
- UHC-20908-36
- Date of birth
- 1976-12-17
- Identity
- Verified2 records, confidence 0.97
- Claim record
- CLMCLM-404323
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0233
- Coverage period
- 2024-09-01 to present
- Deductible
- $651.34 of $1,500.0043%
- Out-of-pocket maximum
- $1,001.41 of $6,000.0017%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 19 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 1928747868
- Network
- In network
- Rendering NPI
- 1928747868
- Location
- Mesa, AZ · TIN 30-6800456
- Authorisation / referral
- PA2025309856 / 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 | $2,053.00 | $1,129.15 | — | — | Review |
| Totals | $2,053.00 | $1,129.15 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-429382
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-004224 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2025-12-15: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025309856 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Community Hospital (1928747868). | |
| 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 Community Hospital2025-12-15 18:43
Follow-up for encounter for general adult medical examination without abnormal findings. Plan discussed, medications reconciled. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-14 06:16
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 letterPA2025309856_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-15 to 2026-03-15.
- Itemized billitemized_PA-429382.pdf8 pages
Itemised statement totalling $2053.00 across 1 line.
- Medical recordrecords_PA-429382.pdf13 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-23 19:13The claim for an MRI brain with and without contrast (70553) was billed with a routine examination diagnosis (Z00.00). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms documented [N1]. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here [N2]. Therefore, the service is not medically necessary per payer policy [CO50].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 19:13 · 19826cf2
Other claims for this member
Same resolved identity
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 examination diagnosis (Z00.00). The clinical note indicates this was a routine screening visit with no acute findings or red-flag symptoms documented [N1]. According to payer policy, advanced imaging with a routine examination diagnosis is payable only when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here [N2]. Therefore, the service is not medically necessary per payer policy [CO50].
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.