CLM-2026-030644
Mesa Medical Group, Family Medicine. Service 2026-03-01 at outpatient hospital (POS 22). Received 2026-03-16.
Member
Resolved through the identity graph
- Member
- Jeremy Pierce
- Member ID
- UHC-58693-80
- Date of birth
- 1955-06-26
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-432571
- Relationship
- Spouse, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8333
- Coverage period
- 2025-08-01 to present
- Deductible
- $2,383.63 of $3,500.0068%
- Out-of-pocket maximum
- $2,337.95 of $10,500.0022%
- Copays
- office $40.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 7662849547
- Network
- In network
- Rendering NPI
- 9614108626
- Location
- Los Angeles, CA · TIN 30-7296562
- Authorisation / referral
- PA2026939001 / 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 | $2,802.00 | $1,541.10 | — | — | Review |
| Totals | $2,802.00 | $1,541.10 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-167895
- 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-020129 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-01: CHOICE-PLUS-PPO (PPO), effective 2025-08-01. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026939001 on file for 70553. | |
| Provider network | Pass | In-network provider Mesa Medical Group (7662849547). | |
| 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: Mesa Medical Group2026-03-01 18:27
Patient seen for encounter for general adult medical examination without abnormal findings. 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 system2026-03-16 00:44
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 letterPA2026939001_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-03-01 to 2026-05-30.
- Itemized billitemized_PA-167895.pdf9 pages
Itemised statement totalling $2802.00 across 1 line.
- Medical recordrecords_PA-167895.pdf20 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 engineReview2026-10-22 12:44Medical necessity: 70553 billed with routine diagnosis Z00.00; clinical notes must support necessity.
Other claims for this member
Same resolved identity
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.