CLM-2026-030071
Sunrise Community Hospital, Emergency Medicine. Service 2025-12-29 at outpatient hospital (POS 22). Received 2026-01-01.
Member
Resolved through the identity graph
- Member
- Luis Carlson
- Member ID
- UHC-63765-77
- Date of birth
- 1962-02-07
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-407735
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5245
- Coverage period
- 2021-05-01 to present
- Deductible
- $809.31 of $1,000.0081%
- Out-of-pocket maximum
- $203.91 of $3,000.007%
- Copays
- office $30.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Sunrise Community HospitalEmergency Medicine · taxonomy 207P00000X
- NPI
- 2310065109
- Network
- In network
- Rendering NPI
- 2310065109
- Location
- Mesa, AZ · TIN 51-3085459
- Authorisation / referral
- PA2025614235 / 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 | $3,173.00 | $1,745.15 | — | — | Review |
| Totals | $3,173.00 | $1,745.15 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-241110
- Frequency code
- 1 (original)
- Accident
- Yes
- 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-000284 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-29: NULL (PPO), effective 2021-05-01. | |
| 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 PA2025614235 on file for 70553. | |
| Provider network | Pass | In-network provider Sunrise Community Hospital (2310065109). | |
| 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: Sunrise Community Hospital2025-12-29 10:10
Patient seen for encounter for general adult medical examination without abnormal findings. Routine screening visit; no acute findings, no red-flag symptoms documented.
- SystemSystem: Claims system2026-01-01 03:01
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 letterPA2025614235_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-241110.pdf9 pages
Itemised statement totalling $3173.00 across 1 line.
- Medical recordrecords_PA-241110.pdf22 pages
Clinic notes for a routine annual visit; no symptoms documented.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
- AI recommendationDenied2026-10-21 14:05The claim for an MRI brain with and without contrast (70553) was billed with a routine diagnosis (Z00.00) for a general adult medical examination without abnormal findings. The clinical note [N1] confirms this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is only payable when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy [R-clinical_edit].
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:05 · f5f615c0
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) for a general adult medical examination without abnormal findings. The clinical note [N1] confirms this was a routine screening visit with no acute findings or red-flag symptoms. According to payer policy, advanced imaging with a routine examination diagnosis is only payable when the clinical note documents failed conservative treatment or red-flag symptoms, which is not the case here. Therefore, the service is not medically necessary per payer policy [R-clinical_edit].
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.