CLM-2026-028661
Riverside Medical Group, Family Medicine. Service 2026-07-21 at outpatient hospital (POS 22). Received 2026-08-29.
Member
Resolved through the identity graph
- Member
- Jack Fowler
- Member ID
- UHC-96462-49
- Date of birth
- 1955-03-01
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412519
- Relationship
- Spouse, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-1956
- Coverage period
- 2022-09-01 to present
- Deductible
- $257.40 of $500.0051%
- Out-of-pocket maximum
- $142.28 of $1,500.009%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 8250558730
- Network
- In network
- Rendering NPI
- 2281038135
- Location
- Nashville, TN · TIN 54-5227365
- Authorisation / referral
- PA2026281020 / 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 | $2,765.00 | $1,520.75 | — | — | Review |
| Totals | $2,765.00 | $1,520.75 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-298758
- 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-033680 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-21: MEDICARE-ADV-A (MA), effective 2022-09-01. | |
| Timely filing | Pass | Received 39 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026281020 on file for 70553. | |
| Provider network | Pass | In-network provider Riverside Medical Group (8250558730). | |
| 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 Medical Group2026-07-21 14:10
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-08-29 04:46
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-29 08:13
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterPA2026281020_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-07-21 to 2026-10-19.
- Itemized billitemized_PA-298758.pdf9 pages
Itemised statement totalling $2765.00 across 1 line.
- Medical recordrecords_PA-298758.pdf14 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-011896 | 2026-07-17 | Meadow Primary Care Associates | $18.00 | Denied |
| CLM-2026-011895 | 2026-07-17 | Meadow Primary Care Associates | $18.00 | Approved |
| CLM-2026-022687 | 2026-02-20 | Sunrise Dermatology Clinic | $755.00 | 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.