CLM-2026-001368
Northgate Cardiovascular Associates, Cardiology. Service 2026-03-26 at outpatient hospital (POS 22). Received 2026-04-25.
Member
Resolved through the identity graph
- Member
- Mason Murray
- Member ID
- UHC-24206-53
- Date of birth
- 1956-08-08
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-421733
- Relationship
- Spouse
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-8943
- Coverage period
- 2024-06-01 to present
- Deductible
- $1,233.32 of $3,500.0035%
- Out-of-pocket maximum
- $1,062.39 of $10,500.0010%
- Copays
- office $20.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 8169098166
- Location
- Los Angeles, CA · TIN 22-8335037
- Authorisation / referral
- PA2026981182 / 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $545.00 | $299.75 | — | — | PendedIDQ |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,888.00 | $4,338.40 | — | — | PendedIDQ |
| Totals | $8,433.00 | $4,638.15 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-312024
- 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 | Fail | IDQ | Member record is in open steward case CASE-002500; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-03-26: MEDICARE-ADV-B (MA), effective 2024-06-01. | |
| Timely filing | Pass | Received 30 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026981182 on file for 93458. | |
| 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 Associates2026-03-26 11:34
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026981182_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-03-26 to 2026-06-24.
- Itemized billitemized_PA-312024.pdf8 pages
Itemised statement totalling $8433.00 across 2 lines.
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-002500; payment withheld until the identity is confirmed.
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.