CLM-2026-032124
Unity Medical Group, Family Medicine. Service 2025-12-08 at outpatient hospital (POS 22). Received 2026-01-05.
Member
Resolved through the identity graph
- Member
- Bryan McDonald
- Member ID
- UHC-55577-57
- Date of birth
- 1943-01-28
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-401483
- Relationship
- Spouse, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6298
- Coverage period
- 2022-05-01 to present
- Deductible
- $1,654.19 of $3,500.0047%
- Out-of-pocket maximum
- $6,924.67 of $14,000.0049%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Medical GroupFamily Medicine · taxonomy 207Q00000X
- NPI
- 6749849405
- Network
- In network
- Rendering NPI
- 2391946102
- Location
- Houston, TX · TIN 69-3600999
- Authorisation / referral
- PA2025727592 / 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 | $2,231.00 | $1,227.05 | — | — | Review |
| Totals | $2,231.00 | $1,227.05 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E11.9 Type 2 diabetes mellitus without complications
- Patient account
- PA-494124
- 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-001140 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-08: CHOICE-PLUS-PPO (PPO), effective 2022-05-01. | |
| Timely filing | Pass | Received 28 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025727592 on file for 70553. | |
| Provider network | Pass | In-network provider Unity Medical Group (6749849405). | |
| 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: Unity Medical Group2025-12-08 18:07
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 system2026-01-05 02:55
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 letterPA2025727592_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-08 to 2026-03-08.
- Itemized billitemized_PA-494124.pdf8 pages
Itemised statement totalling $2231.00 across 1 line.
- Medical recordrecords_PA-494124.pdf7 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 14:14The claim for an MRI brain with and without contrast (70553) is supported by a prior authorisation (PA2025727592) and clinical notes (N1) that document progressive neurological symptoms and failed conservative therapy over 8 weeks. The service is deemed medically necessary to rule out a structural cause. The claim is within the timely filing limit, and the provider is in-network. The billed amount is below the auto-adjudication ceiling, and the member is eligible for the service. The claim history shows a similar service (H1) that is currently under review, but this does not affect the current claim's adjudication.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:14 · b5ec2d67
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009009 | 2025-12-20 | Pinecrest Reference Lab | $2,869.00 | 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 (PA2025727592) and clinical notes (N1) that document progressive neurological symptoms and failed conservative therapy over 8 weeks. The service is deemed medically necessary to rule out a structural cause. The claim is within the timely filing limit, and the provider is in-network. The billed amount is below the auto-adjudication ceiling, and the member is eligible for the service. The claim history shows a similar service (H1) that is currently under review, but this does not affect the current claim's adjudication.
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.