CLM-2026-029413
Heritage Behavioral Health, Behavioral Health. Service 2025-12-26 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Sophia Hunt
- Member ID
- UHC-36645-75
- Date of birth
- 1997-11-18
- Identity
- Verified7 records, confidence 0.99
- Claim record
- CLMCLM-425255
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6401
- Coverage period
- 2021-07-01 to present
- Deductible
- $702.99 of $3,500.0020%
- Out-of-pocket maximum
- $1,649.40 of $7,000.0024%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Behavioral HealthBehavioral Health · taxonomy 103T00000X
- NPI
- 3499047843
- Network
- In network
- Rendering NPI
- 2298810435
- Location
- Minneapolis, MN · TIN 71-8171673
- Authorisation / referral
- PA2025706480 / 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 | $2,154.00 | $1,184.70 | — | — | Review |
| Totals | $2,154.00 | $1,184.70 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. F43.10 Post-traumatic stress disorder, unspecified
- Patient account
- PA-313110
- 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-005512 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: UNKNOWN (PPO), effective 2021-07-01. | |
| 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 PA2025706480 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Behavioral Health (3499047843). | |
| 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: Heritage Behavioral Health2025-12-26 11:18
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 system2026-01-18 05:39
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 letterPA2025706480_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-26 to 2026-03-26.
- Itemized billitemized_PA-313110.pdf4 pages
Itemised statement totalling $2154.00 across 1 line.
- Medical recordrecords_PA-313110.pdf8 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-2026-023577 | 2026-08-26 | Valley Family Practice | $24.00 | Approved |
| CLM-2026-024053 | 2026-06-23 | Northgate Primary Care Associates | $602.00 | Approved |
| CLM-2026-013855 | 2026-04-19 | Summit Endocrine Associates | $259.00 | Denied |
| CLM-2026-013854 | 2026-04-19 | Summit Endocrine Associates | $259.00 | Approved |
| CLM-2026-007710 | 2025-12-07 | Meadow Bone and Joint Center | $1,283.00 | 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.