CLM-2026-001644
Desert Heart Institute, Cardiology. Service 2026-04-29 at outpatient hospital (POS 22). Received 2026-05-05.
Member
Resolved through the identity graph
- Member
- Dylan Stewart
- Member ID
- UHC-17496-87
- Date of birth
- 1969-11-13
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-407160
- Relationship
- Spouse, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-5312
- Coverage period
- 2022-01-01 to present
- Deductible
- $716.57 of $1,500.0048%
- Out-of-pocket maximum
- $869.23 of $6,000.0014%
- Copays
- office $25.00, specialist $40.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 3412096463
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- PA2025935606 / 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 | $1,364.00 | $750.20 | $750.20 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $6,855.00 | $3,770.25 | $406.93 | $3,363.32 | Paid |
| Totals | $8,219.00 | $4,520.45 | $1,157.13 | $3,363.32 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-767319
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-020815 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-29: MEDICARE-ADV-B (MA), effective 2022-01-01. | |
| Timely filing | Pass | Received 6 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025935606 on file for 93458. | |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-04-29 10:35
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2025935606_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-04-29 to 2026-07-28.
- Itemized billitemized_PA-767319.pdf3 pages
Itemised statement totalling $8219.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006911 | 2026-06-07 | Mesa Internal Medicine Associates | $470.00 | Needs review |
| CLM-2026-013603 | 2026-02-25 | Lakeside Reference Lab | $64.00 | Approved |
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
Clean claim, priced at contract rate.