CLM-2026-029553
Heritage Community Hospital, Emergency Medicine. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-10.
Member
Resolved through the identity graph
- Member
- Mark Howlel
- Member ID
- UHC-14995-76
- Date of birth
- 1940-07-09
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-401874
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7301
- Coverage period
- 2025-07-01 to present
- Deductible
- $384.45 of $2,500.0015%
- Out-of-pocket maximum
- $1,735.14 of $7,500.0023%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Heritage Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 9421157162
- Network
- In network
- Rendering NPI
- 9421157162
- Location
- Scottsdale, AZ · TIN 26-8049060
- Authorisation / referral
- PA2026681337 / 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 | $2,656.00 | $1,460.80 | — | — | Review |
| Totals | $2,656.00 | $1,460.80 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. R10.9 Unspecified abdominal pain
- Patient account
- PA-105107
- 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-003040 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: OPTIONS-PPO (PPO), effective 2025-07-01. | |
| Timely filing | Pass | Received 11 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026681337 on file for 70553. | |
| Provider network | Pass | In-network provider Heritage Community Hospital (9421157162). | |
| 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 Community Hospital2025-12-30 15:30
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-10 00:07
Clinical edit: advanced imaging billed with a routine examination diagnosis. Sent to nurse review for medical necessity.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-01-10 11:01
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Prior auth letterPA2026681337_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-30 to 2026-03-30.
- Itemized billitemized_PA-105107.pdf7 pages
Itemised statement totalling $2656.00 across 1 line.
- Medical recordrecords_PA-105107.pdf21 pages
Clinic notes for a routine annual visit; no symptoms documented.
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.
- AI recommendationDenied2026-10-23 17:08The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not document any acute findings, red-flag symptoms, or failed conservative treatment. Therefore, the service is not medically necessary per payer policy (CO50).
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-22 12:43 · 393d312c
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-23 17:08 · 82e2a1fc
Other claims for this member
Same resolved identity
AI recommendation
apac.amazon.nova-pro-v1:0 · prompt adjudicate-v1 · policy v1 · assist mode
- CO50 Not medically necessary per payer policy
The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) and the clinical note does not document any acute findings, red-flag symptoms, or failed conservative treatment. Therefore, the service is not medically necessary per payer policy (CO50).
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
- CO50 Not medically necessary per payer policy
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Routine diagnosis does not support advanced imaging.