CLM-2026-034204
Canyon Primary Care Associates, Family Medicine. Service 2026-01-04 at outpatient hospital (POS 22). Received 2026-02-02.
Member
Resolved through the identity graph
- Member
- Brandon Torres
- Member ID
- UHC-26652-20
- Date of birth
- 1955-11-27
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-414501
- Relationship
- Spouse, Chandler, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-4644
- Coverage period
- 2023-06-01 to present
- Deductible
- $233.92 of $500.0047%
- Out-of-pocket maximum
- $567.42 of $2,000.0028%
- Copays
- office $20.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Canyon Primary Care AssociatesFamily Medicine · taxonomy 207Q00000X
- NPI
- 2780458347
- Network
- In network
- Rendering NPI
- 3136944816
- Location
- Miami, FL · TIN 49-9122267
- Authorisation / referral
- PA2026078006 / 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 | $2,174.00 | $1,195.70 | — | — | Review |
| Totals | $2,174.00 | $1,195.70 | — | — | ||||||
- 1. Z00.00 Encounter for general adult medical examination without abnormal findingsprincipal
- 2. E78.5 Hyperlipidemia, unspecified
- Patient account
- PA-140395
- 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-009781 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-04: MEDICARE-ADV-B (MA), effective 2023-06-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026078006 on file for 70553. | |
| Provider network | Pass | In-network provider Canyon Primary Care Associates (2780458347). | |
| 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 Primary Care Associates2026-01-04 11:54
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 system2026-02-02 01:51
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 letterPA2026078006_approval.pdf2 pages
Utilisation management approval letter for 70553 (MRI brain with and without contrast), valid 2026-01-04 to 2026-04-04.
- Itemized billitemized_PA-140395.pdf2 pages
Itemised statement totalling $2174.00 across 1 line.
- Medical recordrecords_PA-140395.pdf14 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.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017383 | 2026-06-20 | Northgate Internal Medicine Associates | $316.00 | Approved |
| CLM-2026-034575 | 2026-06-01 | Pinecrest Medical Group | $36.00 | Approved |
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
Routine diagnosis does not support advanced imaging.