CLM-2026-001678
Valley Cardiovascular Associates, Cardiology. Service 2025-12-21 at outpatient hospital (POS 22). Received 2026-01-09.
Member
Resolved through the identity graph
- Member
- Helen West
- Member ID
- UHC-20637-25
- Date of birth
- 1953-01-09
- Identity
- Verified3 records, confidence 0.96
- Claim record
- CLMCLM-411866
- Relationship
- Self, Mesa, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-7621
- Coverage period
- 2025-10-01 to present
- Deductible
- $2,251.84 of $3,500.0064%
- Out-of-pocket maximum
- $763.86 of $14,000.005%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4553481845
- Network
- In network
- Rendering NPI
- 7495435514
- Location
- Dallas, TX · TIN 18-8856969
- Authorisation / referral
- PA2026372963 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,729.00 | $4,800.95 | $1,603.44 | $3,197.51 | Paid |
| 2 | 93015 | Cardiovascular stress test | 25 | 1 | 1 | $649.00 | $356.95 | $35.70 | $321.25 | Paid |
| Totals | $9,378.00 | $5,157.90 | $1,639.14 | $3,518.76 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-139451
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-002772 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-12-21: SELECT-EPO (EPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 19 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026372963 on file for 93458. | |
| Provider network | Pass | In-network provider Valley Cardiovascular Associates (4553481845). | |
| 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 Cardiovascular Associates2025-12-21 17:55
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026372963_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2025-12-21 to 2026-03-21.
- Itemized billitemized_PA-139451.pdf8 pages
Itemised statement totalling $9378.00 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-2026-015022 | 2026-08-09 | Lakeside Reference Lab | $52.00 | Approved |
| CLM-2026-018117 | 2026-05-22 | Sunrise Counseling Center | $453.00 | 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.