As paid vs. as it should have been
| Ln | Code | Description | Paid | Should be | Variance | Result |
|---|---|---|---|---|---|---|
| 1 | 70553 |
MRI, brain, without contrast material, followed by contrast and further sequences
G43.109 · Migraine with aura, intractable, without status migrainosus
|
$316.97 | $316.97 | — | Correct |
Determination
Reviewed with no variance. Every line was paid at the allowable on file.
How it was coded
Remedy: None — the claim was billed and priced as the record supports
Reviewed for level, severity and unit count. A single study, one unit, paid at the fee schedule allowable.
Prior authorization
Authorised in advance and billed as authorised. Under CPP-085 v3.4 that closes medical necessity for this study — the post-service review is limited to whether it was coded and priced correctly, and it was.
Policy applied
Knowledge CenterCoverage conditions for advanced imaging, and the Florida variation that applies to this member
No source document for v1.3 is in the index, so this policy can be cited here but not quoted. Upload it.
Coverage on the date of service, and the re-verification at audit
v6.1 was extracted from CPP-080_eligibility-enrolment-retroactive-termination_v6.1.md. Passages are quoted only on the policy the finding rests on.
The authorization on file, and what it closes off from post-service review
v3.4 was extracted from CPP-085_prior-authorization-post-service-review_v3.4.md. Passages are quoted only on the policy the finding rests on.