CLM-2026-001347
Northgate Cardiovascular Associates, Cardiology. Service 2025-12-09 at office (POS 11). Received 2026-01-19.
Member
Resolved through the identity graph
- Member
- Austin Bryant
- Member ID
- none on golden record
- Date of birth
- 1970-09-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418903
- Relationship
- Child
Coverage and accumulators
Found by name and date of birth
- Plan
- - PPO group N/A
- Coverage period
- 2023-09-01 to present
- Deductible
- $950.23 of $1,500.0063%
- Out-of-pocket maximum
- $67.29 of $3,000.002%
- Copays
- office $30.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 1350850107
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $388.00 | $240.56 | — | — | PendedIDQ |
| Totals | $388.00 | $240.56 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- Patient account
- PA-551743
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-000998; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2025-12-09: - (PPO), effective 2023-09-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 41 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 Northgate Cardiovascular Associates (5594465275). | |
| 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 Cardiovascular Associates2025-12-09 09:42
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-000998; payment withheld until the identity is confirmed. Eligibility: Active on 2025-12-09: - (PPO), effective 2023-09-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.