CLM-2026-002038
Northgate Heart Institute, Cardiology. Service 2026-05-18 at outpatient hospital (POS 22). Received 2026-06-24.
Member
Resolved through the identity graph
- Member
- Mateo Obrien
- Member ID
- UHC-64674-51
- Date of birth
- 1969-03-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-412373
- Relationship
- Self, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-3392
- Coverage period
- 2021-05-01 to present
- Deductible
- $1,357.28 of $2,500.0054%
- Out-of-pocket maximum
- $2,167.29 of $10,000.0022%
- Copays
- office $40.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 8173646471
- Location
- San Diego, CA · TIN 46-7688844
- 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 | $1,165.00 | $640.75 | $640.75 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $366.00 | $201.30 | $201.30 | $0.00 | Paid |
| Totals | $1,531.00 | $842.05 | $842.05 | $0.00 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-439760
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-009521 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-18: NULL (PPO), effective 2021-05-01. | |
| Timely filing | Pass | Received 37 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (5192135197). | |
| 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 Heart Institute2026-05-18 14:04
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Itemized billitemized_PA-439760.pdf5 pages
Itemised statement totalling $1531.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029932 | 2026-04-25 | Riverside Imaging Center | $2,240.00 | Denied |
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.