CLM-2026-002185
Summit Cardiovascular Associates, Cardiology. Service 2026-04-28 at outpatient hospital (POS 22). Received 2026-05-28.
Member
Resolved through the identity graph
- Member
- Frances Ross
- Member ID
- UHC-49985-38
- Date of birth
- 1987-12-11
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-426688
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3625
- Coverage period
- 2025-04-01 to present
- Deductible
- $799.08 of $3,500.0023%
- Out-of-pocket maximum
- $1,449.64 of $10,500.0014%
- Copays
- office $40.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 14 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 1054709310
- Location
- Houston, TX · TIN 53-6389420
- 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 | $1,391.00 | $765.05 | $765.05 | $0.00 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $438.00 | $240.90 | $240.90 | $0.00 | Paid |
| Totals | $1,829.00 | $1,005.95 | $1,005.95 | $0.00 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-523157
- 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-018682 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-04-28: MEDICARE-ADV-A (MA), effective 2025-04-01. | |
| Timely filing | Pass | Received 30 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 Summit Cardiovascular Associates (5138686964). | |
| 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: Summit Cardiovascular Associates2026-04-28 14:46
Established patient presents with atherosclerotic heart disease of native coronary artery without angina; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-523157.pdf5 pages
Itemised statement totalling $1829.00 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-2026-000253 | 2026-05-11 | Evergreen Internal Medicine Associates | $79.00 | Needs review |
| CLM-2026-000252 | 2026-05-11 | Evergreen Internal Medicine Associates | $79.00 | 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.