CLM-2026-029724
Canyon Internal Medicine Associates, Internal Medicine. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Raymond Walsh
- Member ID
- UHC-09175-90
- Date of birth
- 1951-11-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-400011
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7045
- Coverage period
- 2025-09-01 to present
- Deductible
- $981.92 of $1,500.0065%
- Out-of-pocket maximum
- $1,105.40 of $4,500.0025%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Internal Medicine AssociatesInternal Medicine · taxonomy 207R00000X
- NPI
- 3068658913
- Network
- In network
- Rendering NPI
- 8372439942
- Location
- San Diego, CA · TIN 88-5368681
- Authorisation / referral
- PA2026413977 / 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 | $2,372.00 | $1,304.60 | — | — | Review |
| Totals | $2,372.00 | $1,304.60 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-831363
- 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-000241 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-29: N/A (PPO), effective 2025-09-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026413977 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Internal Medicine Associates (3068658913). | |
| 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: Canyon Internal Medicine Associates2025-12-29 10:53
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 system2026-01-01 06:58
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 letterPA2026413977_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-29 to 2026-03-29.
- Itemized billitemized_PA-831363.pdf8 pages
Itemised statement totalling $2372.00 across 1 line.
- Medical recordrecords_PA-831363.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 14:05The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2026413977) and clinical notes (N1) that document 8 weeks of failed conservative therapy and progressive neurological symptoms, which justifies the medical necessity of the imaging. The provider is in-network, and the claim is within the auto-adjudication ceiling. The member is eligible, and the claim was received within the timely filing limit. The claim is approved, but requires human sign-off due to the billed amount above $15,000.00.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · a2b0b5e5
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026673 | 2026-07-23 | Pinecrest Cardiovascular Associates | $283.00 | Approved |
| CLM-2026-022863 | 2026-06-21 | Northgate Clinical Laboratories | $135.00 | Approved |
| CLM-2026-011576 | 2025-12-04 | Mesa Reference Lab | $136.00 | Needs review |
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 a prior authorisation (PA2026413977) and clinical notes (N1) that document 8 weeks of failed conservative therapy and progressive neurological symptoms, which justifies the medical necessity of the imaging. The provider is in-network, and the claim is within the auto-adjudication ceiling. The member is eligible, and the claim was received within the timely filing limit. The claim is approved, but requires human sign-off due to the billed amount above $15,000.00.
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.