CLM-2026-000817
Northgate Heart Institute, Cardiology. Service 2026-01-23 at outpatient hospital (POS 22). Received 2026-07-01.
Member
Resolved through the identity graph
- Member
- Willie Chavez
- Member ID
- UHC-34974-99
- Date of birth
- 2007-02-03
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427349
- Relationship
- Child, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-0541
- Coverage period
- 2025-11-01 to present
- Deductible
- $143.07 of $1,000.0014%
- Out-of-pocket maximum
- $951.18 of $3,000.0032%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 18 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 8883034430
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- none / REF360627
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 | $1,341.00 | $737.55 | — | — | DeniedCO29 |
| Totals | $1,341.00 | $737.55 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-855693
- 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-027005 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-23: NAVIGATE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Fail | CO29 | Received 159 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 Institute2026-01-23 16:20
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-01 04:39
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: R. Patel (Claims Examiner II)2026-07-01 09:56
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-855693.pdf8 pages
Itemised statement totalling $1341.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 159 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-023852 | 2026-07-05 | Mesa Diabetes Center | $216.00 | Approved |
| CLM-2026-005417 | 2026-05-01 | Pinecrest Medical Group | $154.00 | Approved |
| CLM-2026-017312 | 2026-03-07 | Summit Reference Lab | $194.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.