CLM-2026-001275
Unity Cardiovascular Associates, Cardiology. Service 2026-07-05 at outpatient hospital (POS 22). Received 2026-07-12.
Member
Resolved through the identity graph
- Member
- Bradley Santiago
- Member ID
- UHC-26632-77
- Date of birth
- 1976-02-23
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-429748
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-0916
- Coverage period
- 2024-02-01 to 2026-01-05
- Deductible
- $848.31 of $1,000.0085%
- Out-of-pocket maximum
- $697.81 of $2,000.0035%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 2707857662
- Location
- Nashville, TN · TIN 22-5957660
- 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 | $1,078.00 | $592.90 | — | — | DeniedCO27 |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 2 | $595.00 | $327.25 | — | — | DeniedCO27 |
| Totals | $1,673.00 | $920.15 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-221819
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-035531 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-05 is after coverage terminated on 2026-01-05. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 7 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 Unity Cardiovascular Associates (6971241222). | |
| 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: Unity Cardiovascular Associates2026-07-05 09:08
Patient seen for unspecified atrial fibrillation.
- SystemSystem: Claims system2026-07-12 02:37
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-07-12 15:27
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
- Itemized billitemized_PA-221819.pdf5 pages
Itemised statement totalling $1673.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-05 is after coverage terminated on 2026-01-05.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033443 | 2026-06-07 | Pinecrest Cardiovascular Associates | $718.00 | Denied |
| CLM-2026-003564 | 2026-05-28 | Mesa Family Practice | $334.00 | 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
Service after coverage termination.