CLM-2026-027610
Lakeside Imaging Center, Radiology. Service 2025-12-15 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Dorothy Fulelr
- Member ID
- UHC-32368-14
- Date of birth
- 1970-03-20
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-431879
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-1708
- Coverage period
- 2022-02-01 to present
- Deductible
- $637.51 of $1,500.0043%
- Out-of-pocket maximum
- $347.48 of $6,000.006%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Imaging CenterRadiology · taxonomy 2085R0202X
- NPI
- 4829743648
- Network
- In network
- Rendering NPI
- 4829743648
- Location
- Minneapolis, MN · TIN 87-3632325
- Authorisation / referral
- PA2025009630 / 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 | $1,862.00 | $1,024.10 | — | — | Review |
| Totals | $1,862.00 | $1,024.10 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R07.9 Chest pain, unspecified
- 3. Z12.31 Encounter for screening mammogram for malignant neoplasm of breast
- Patient account
- PA-749895
- 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-001997 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-15: OPTIONS-PPO (PPO), effective 2022-02-01. | |
| Timely filing | Pass | Received 23 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025009630 on file for 70553. | |
| Provider network | Pass | In-network provider Lakeside Imaging Center (4829743648). | |
| 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: Lakeside Imaging Center2025-12-15 13:24
Patient seen for encounter for general adult medical examination without abnormal findings. 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 system2026-01-07 04:03
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 letterPA2025009630_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-749895.pdf5 pages
Itemised statement totalling $1862.00 across 1 line.
- Medical recordrecords_PA-749895.pdf19 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 engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationApproved2026-10-21 14:15The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025009630) and is from an in-network provider. The clinical note [N1] and medical record [A3] document progressive neurological symptoms and failed conservative therapy over 8 weeks, which supports the medical necessity of the imaging. The claim is within the timely filing limit and does not exceed the auto-adjudication ceiling. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 25d042f2
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025009630) and is from an in-network provider. The clinical note [N1] and medical record [A3] document progressive neurological symptoms and failed conservative therapy over 8 weeks, which supports the medical necessity of the imaging. The claim is within the timely filing limit and does not exceed the auto-adjudication ceiling. Therefore, the claim is approved.
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.