CLM-2026-027929
Mesa Behavioral Health, Behavioral Health. Service 2026-08-10 at outpatient hospital (POS 22). Received 2026-09-06.
Member
Resolved through the identity graph
- Member
- Gabriel McDonald
- Member ID
- UHC-21533-16
- Date of birth
- 1947-11-21
- Identity
- Verified5 records, confidence 0.96
- Claim record
- CLMCLM-402954
- Relationship
- Self, Plano, TX
Coverage and accumulators
Found by member ID
- Plan
- NULL PPO group NULL
- Coverage period
- 2022-10-01 to present
- Deductible
- $420.18 of $500.0084%
- Out-of-pocket maximum
- $137.76 of $1,500.009%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 7796147859
- Network
- In network
- Rendering NPI
- 5012840638
- Location
- Nashville, TN · TIN 40-4103519
- Authorisation / referral
- PA2026955229 / 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 | $2,694.00 | $1,481.70 | — | — | Review |
| Totals | $2,694.00 | $1,481.70 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. F32.1 Major depressive disorder, single episode, moderate
- Patient account
- PA-109387
- 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-012826 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2026-08-10: NULL (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 27 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026955229 on file for 70553. | |
| Provider network | Pass | In-network provider Mesa Behavioral Health (7796147859). | |
| 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 Behavioral Health2026-08-10 16:23
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 system2026-09-06 01:40
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-09-06 10:41
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterPA2026955229_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-08-10 to 2026-11-08.
- Itemized billitemized_PA-109387.pdf9 pages
Itemised statement totalling $2694.00 across 1 line.
- Medical recordrecords_PA-109387.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 engineReview2026-10-22 12:44Medical 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-2026-010535 | 2026-09-13 | Riverside GI Associates | $5,049.00 | Approved |
| CLM-2026-019346 | 2026-06-02 | Sunrise Counseling Center | $482.00 | Approved |
| CLM-2026-007679 | 2026-03-24 | Heritage Physical Therapy | $563.00 | Denied |
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.