CLM-2026-001199
Valley Heart Institute, Cardiology. Service 2026-06-28 at outpatient hospital (POS 22). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Teresa Harvey
- Member ID
- UHC-30222-34
- Date of birth
- 1995-07-24
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-401924
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1194
- Coverage period
- 2022-11-01 to present
- Deductible
- $541.50 of $1,000.0054%
- Out-of-pocket maximum
- $580.66 of $2,000.0029%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 3852055177
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- none / REF312468
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 | $7,845.00 | $4,314.75 | — | — | DeniedCO197 |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,211.00 | $666.05 | — | — | DeniedCO197 |
| Totals | $9,056.00 | $4,980.80 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-302933
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-031394 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-06-28: NAVIGATE-HMO (HMO), effective 2022-11-01. | |
| Timely filing | Pass | Received 45 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Valley Heart Institute (9412184639). | |
| 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: Valley Heart Institute2026-06-28 16:08
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-08-12 00:35
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-08-12 12:10
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-302933.pdf7 pages
Itemised statement totalling $9056.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-003051 | 2026-05-03 | Riverside Clinical Laboratories | $111.00 | Approved |
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
Precertification required and absent.