CLM-2026-033102
Pinecrest Family Practice, Family Medicine. Service 2026-06-13 at outpatient hospital (POS 22). Received 2026-06-19.
Member
Resolved through the identity graph
- Member
- Sophia Graham
- Member ID
- UHC-79154-47
- Date of birth
- 1967-09-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-405971
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-3132
- Coverage period
- 2023-04-01 to present
- Deductible
- $151.63 of $3,500.004%
- Out-of-pocket maximum
- $270.80 of $7,000.004%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Pinecrest Family PracticeFamily Medicine · taxonomy 207Q00000X
- NPI
- 9590925530
- Network
- In network
- Rendering NPI
- 3619371339
- Location
- Denver, CO · TIN 80-5640290
- Authorisation / referral
- PA2026214231 / 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 | $2,946.00 | $1,620.30 | — | — | PendedIDQ |
| Totals | $2,946.00 | $1,620.30 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-476220
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-003027; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-13: MEDICARE-ADV-B (MA), effective 2023-04-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026214231 on file for 70553. | |
| Provider network | Pass | In-network provider Pinecrest Family Practice (9590925530). | |
| 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: Pinecrest Family Practice2026-06-13 09:55
Established patient presents with encounter for general adult medical examination without abnormal findings; symptoms reviewed and vitals within expected range. 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 system2026-06-19 04:43
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 letterPA2026214231_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-06-13 to 2026-09-11.
- Itemized billitemized_PA-476220.pdf2 pages
Itemised statement totalling $2946.00 across 1 line.
- Medical recordrecords_PA-476220.pdf9 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 enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003027; payment withheld until the identity is confirmed. Medical 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.