Claims workbench/CLM-2026-001971

Institutional claim · UB-04 · EDI 837I

CLM-2026-001971

Pinecrest Heart Institute, Cardiology. Service 2026-03-16 at outpatient hospital (POS 22). Received 2026-04-09.

Needs review

Billed

$10,130.00

2 lines

Allowed

$5,571.50

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Nathan Hernandez
Member ID: UHC-51466-53
Date of birth: 1998-09-28
Identity: Verified4 records, confidence 0.96
Claim record: CLMCLM-432048
Relationship: Self, Fresno, CA

Coverage and accumulators

Found by member ID

Plan: CORE-HMO HMO group GRP-1010
Coverage period: 2021-05-01 to present
Deductible: $1,333.14 of $1,500.0089%
Out-of-pocket maximum: $448.32 of $4,500.0010%
Copays: office $30.00, specialist $40.00, emergency $350.00
Physical therapy visits: 5 of 20 used

Provider

Billing and rendering

Billing provider: Pinecrest Heart Institute
Cardiology · taxonomy 207RC0000X
NPI: 8218526324
Network: In network
Rendering NPI: 4216228344
Location: Mesa, AZ · TIN 32-1379406
Authorisation / referral: PA2026880189 / REF344573

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	59	1	1	$8,772.00	$4,824.60	—	—	Review
2	93306 rev 0480	Echocardiogram, complete	59	1	1,2	$1,358.00	$746.90	—	—	Review
Totals						$10,130.00	$5,571.50	—	—

Diagnoses (ICD-10-CM)

1. I50.9 Heart failure, unspecifiedprincipal
2. I48.91 Unspecified atrial fibrillation

Claim header

Patient account: PA-166745
Frequency code: 1 (original)
Accident: No
DRG: 287
Admit / discharge: —
Landed: 2026-10-22 12:44

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-017237 (verified, link confidence 0.96).
Eligibility	Pass		Active on 2026-03-16: CORE-HMO (HMO), effective 2021-05-01.
Timely filing	Pass		Received 24 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2026880189 on file for 93458.
Provider network	Pass		In-network provider Pinecrest Heart Institute (8218526324).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-22 12:44 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Pinecrest Heart Institute2026-03-16 15:52
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range. Separate procedure performed at a distinct anatomical site during the same encounter; see operative note for site detail.
SystemSystem: Claims system2026-04-09 03:00
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.
AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-04-09 11:53
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026880189_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-03-16 to 2026-06-14.
Itemized billitemized_PA-166745.pdf8 pages
Itemised statement totalling $10130.00 across 2 lines.
Medical recordrecords_PA-166745.pdf19 pages
Operative note describing procedures at two distinct anatomical sites.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-22 12:44
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-022213	2026-02-26	Mesa Family Practice	$43.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

Approvedscenario: Unbundling supported

Modifier 59 supported: distinct anatomical site documented.

Review queue Member identity