CLM-2026-033567
Canyon Regional Medical Center, Emergency Medicine. Service 2025-12-22 at outpatient hospital (POS 22). Received 2026-01-06.
Member
Resolved through the identity graph
- Member
- Philip Holmes
- Member ID
- UHC-83762-30
- Date of birth
- 1963-12-14
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-420470
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-0245
- Coverage period
- 2022-07-01 to present
- Deductible
- $127.03 of $500.0025%
- Out-of-pocket maximum
- $124.71 of $1,500.008%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Regional Medical CenterEmergency Medicine · taxonomy 207P00000X
- NPI
- 7874072318
- Network
- In network
- Rendering NPI
- 7874072318
- Location
- Tampa, FL · TIN 53-7384078
- Authorisation / referral
- PA2025291013 / 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 | $3,435.00 | $1,889.25 | — | — | Review |
| Totals | $3,435.00 | $1,889.25 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- Patient account
- PA-725906
- 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-001895 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-22: SELECT-EPO (EPO), effective 2022-07-01. | |
| 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 PA2025291013 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Regional Medical Center (7874072318). | |
| 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 Regional Medical Center2025-12-22 11:26
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 system2026-01-06 05:07
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 letterPA2025291013_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2025-12-22 to 2026-03-22.
- Itemized billitemized_PA-725906.pdf3 pages
Itemised statement totalling $3435.00 across 1 line.
- Medical recordrecords_PA-725906.pdf16 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 14:15The claim for an MRI brain with and without contrast (70553) is supported by the clinical note [N1], which documents progressive neurological symptoms and failed conservative therapy over 8 weeks. This meets the payer policy for advanced imaging with a routine examination diagnosis. The prior authorisation [A1] is valid, and the provider is in-network [R-network]. The claim is within the timely filing limit [R-timely_filing] and does not exceed the auto-adjudication ceiling [R-high_dollar]. All required documentation is present [R-completeness], and the member is eligible [R-eligibility]. Therefore, the claim is approved.
- AI recommendation recordedR. Patel (Claims Examiner II)2026-10-21 14:15 · 8a42954c
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033525 | 2026-08-27 | Meadow Bone and Joint Center | $10,285.00 | Approved |
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 the clinical note [N1], which documents progressive neurological symptoms and failed conservative therapy over 8 weeks. This meets the payer policy for advanced imaging with a routine examination diagnosis. The prior authorisation [A1] is valid, and the provider is in-network [R-network]. The claim is within the timely filing limit [R-timely_filing] and does not exceed the auto-adjudication ceiling [R-high_dollar]. All required documentation is present [R-completeness], and the member is eligible [R-eligibility]. Therefore, the claim is approved.
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.