CLM-2026-001949
Unity Cardiovascular Associates, Cardiology. Service 2026-01-12 at outpatient hospital (POS 22). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Valentina Reid
- Member ID
- UHC-92970-85
- Date of birth
- 1965-04-06
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-430896
- Relationship
- Self, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-8788
- Coverage period
- 2025-05-01 to 2026-03-18
- Deductible
- $1,770.95 of $2,500.0071%
- Out-of-pocket maximum
- $1,523.29 of $10,000.0015%
- Copays
- office $20.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 2565639590
- Location
- Austin, TX · TIN 85-7157083
- 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 | $1,002.00 | $551.10 | — | — | DeniedCO29 |
| Totals | $1,002.00 | $551.10 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-225578
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004776 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-12: OPTIONS-PPO (PPO), effective 2025-05-01, terms 2026-03-18. | |
| Timely filing | Fail | CO29 | Received 179 days after the last date of service (limit 90). Time limit for filing has expired |
| 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 (3984509984). | |
| 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 Associates2026-01-12 16:12
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-10 00:42
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-225578.pdf5 pages
Itemised statement totalling $1002.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 179 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
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
Received after the timely-filing limit.