CLM-2026-001196
Cornerstone Cardiovascular Associates, Cardiology. Service 2026-09-25 at outpatient hospital (POS 22). Received 2026-10-12.
Member
Resolved through the identity graph
- Member
- Adam Harper
- Member ID
- UHC-83331-37
- Date of birth
- 1995-09-18
- Identity
- Verified4 records, confidence 0.97
- Claim record
- CLMCLM-414272
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7828
- Coverage period
- 2021-12-01 to present
- Deductible
- $1,100.06 of $2,500.0044%
- Out-of-pocket maximum
- $1,442.27 of $7,500.0019%
- Copays
- office $30.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Cornerstone Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 2414323685
- Network
- In network
- Rendering NPI
- 1042234975
- Location
- Nashville, TN · TIN 96-9778559
- Authorisation / referral
- none / REF532847
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $436.00 | $239.80 | $239.80 | $0.00 | Paid |
| Totals | $436.00 | $239.80 | $239.80 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-638049
- 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-027151 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-09-25: NAVIGATE-HMO (HMO), effective 2021-12-01. | |
| Timely filing | Pass | Received 17 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 Cornerstone Cardiovascular Associates (2414323685). | |
| 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: Cornerstone Cardiovascular Associates2026-09-25 09:25
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-10-12 02:32
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-10-12 09:01
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-638049.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-638049.pdf3 pages
Itemised statement totalling $436.00 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
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
Authorisation must be confirmed with UM before payment.