CLM-2026-029085
Northgate Heart Institute, Cardiology. Service 2025-12-28 at outpatient hospital (POS 22). Received 2026-01-07.
Member
Resolved through the identity graph
- Member
- Cynthia Hunter
- Member ID
- UHC-66546-30
- Date of birth
- 2007-09-01
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-410443
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3536
- Coverage period
- 2024-08-01 to present
- Deductible
- $360.30 of $500.0072%
- Out-of-pocket maximum
- $266.52 of $1,500.0018%
- Copays
- office $25.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 2483774487
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- PA2025231037 / 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 | $2,420.00 | $1,331.00 | — | — | Review |
| Totals | $2,420.00 | $1,331.00 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-278768
- 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-002149 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2025-12-28: UNKNOWN (PPO), effective 2024-08-01. | |
| Timely filing | Pass | Received 10 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025231037 on file for 70553. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (5192135197). | |
| 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: Northgate Heart Institute2025-12-28 14:43
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 system2026-01-07 06:02
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 letterPA2025231037_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-28 to 2026-03-28.
- Itemized billitemized_PA-278768.pdf5 pages
Itemised statement totalling $2420.00 across 1 line.
- Medical recordrecords_PA-278768.pdf22 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 the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks, indicating medical necessity. The prior authorisation [A1] is valid and matches the service date. The provider is in-network [PRV], and the claim is within the timely filing limit [R-timely_filing]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and there are no bundling conflicts [R-ncci]. The member's identity and eligibility are confirmed [R-identity, R-eligibility], and the claim is not a duplicate [R-duplicate]. The medical record [A3] supports the clinical necessity.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 9f2d75b6
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017268 | 2025-12-28 | Riverside Digestive Health Center | $3,470.00 | Approved |
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 the clinical note [N1] which documents progressive neurological symptoms and failed conservative therapy over 8 weeks, indicating medical necessity. The prior authorisation [A1] is valid and matches the service date. The provider is in-network [PRV], and the claim is within the timely filing limit [R-timely_filing]. The billed amount is within the auto-adjudication ceiling [R-high_dollar], and there are no bundling conflicts [R-ncci]. The member's identity and eligibility are confirmed [R-identity, R-eligibility], and the claim is not a duplicate [R-duplicate]. The medical record [A3] supports the clinical necessity.
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.