CLM-2026-000313
Northgate Heart Institute, Cardiology. Service 2025-12-24 at outpatient hospital (POS 22). Received 2026-02-05.
Member
Resolved through the identity graph
- Member
- Alexander Schultz
- Member ID
- UHC-44327-61
- Date of birth
- 1967-11-05
- Identity
- Verified5 records, confidence 0.93
- Claim record
- CLMCLM-411555
- Relationship
- Spouse, Tucson, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-2983
- Coverage period
- 2023-10-01 to present
- Deductible
- $414.08 of $1,500.0028%
- Out-of-pocket maximum
- $2,413.29 of $6,000.0040%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 1366609836
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- none / 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $904.00 | $497.20 | $497.20 | $0.00 | Paid |
| Totals | $904.00 | $497.20 | $497.20 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-410992
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-010604 (verified, link confidence 0.93). | |
| Eligibility | Pass | Active on 2025-12-24: SELECT-EPO (EPO), effective 2023-10-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (5192135197). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| 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: Northgate Heart Institute2025-12-24 17:59
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-410992.pdf6 pages
Itemised statement totalling $904.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005880 | 2026-05-28 | Lakeside Skin Care Associates | $904.00 | Approved |
| CLM-2026-003822 | 2026-01-24 | Mesa Family Practice | $232.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.