CLM-2026-000566
Desert Heart Institute, Cardiology. Service 2026-07-03 at outpatient hospital (POS 22). Received 2026-07-17.
Member
Resolved through the identity graph
- Member
- Douglas Pierce
- Member ID
- UHC-16964-87
- Date of birth
- 1939-01-26
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-409314
- Relationship
- Child, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-5423
- Coverage period
- 2022-10-01 to present
- Deductible
- $90.55 of $2,500.004%
- Out-of-pocket maximum
- $1,470.10 of $7,500.0020%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 3343464236
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- PA2026837641 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,194.00 | $3,406.70 | $2,509.17 | $897.53 | Paid |
| Totals | $6,194.00 | $3,406.70 | $2,509.17 | $897.53 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-999216
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-022078 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-03: N/A (PPO), effective 2022-10-01. | |
| Timely filing | Pass | Received 14 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026837641 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-07-03 15:15
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Prior auth letterPA2026837641_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-07-03 to 2026-10-01.
- Itemized billitemized_PA-999216.pdf9 pages
Itemised statement totalling $6194.00 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-2026-023709 | 2026-06-16 | Sunrise Cardiovascular Associates | $2,028.00 | Approved |
| CLM-2026-023225 | 2026-04-22 | Lakeside Medical Group | $397.00 | Approved |
| CLM-2026-024330 | 2026-02-23 | Meadow Bone and Joint Center | $183.00 | 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.