Claims workbench/CLM-2026-002230

Institutional claim · UB-04 · EDI 837I

CLM-2026-002230

Evergreen Cardiovascular Associates, Cardiology. Service 2025-11-30 at outpatient hospital (POS 22). Received 2026-06-18.

Denied

Billed

$7,988.00

3 lines

Allowed

$4,393.40

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO29

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Evelyn West
Member ID: UHC-84463-14
Date of birth: 1995-12-24
Identity: Verified2 records, confidence 0.99
Claim record: CLMCLM-410520
Relationship: Spouse, Tempe, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-5684
Coverage period: 2025-01-01 to present
Deductible: $1.76 of $1,000.000%
Out-of-pocket maximum: $922.43 of $3,000.0031%
Copays: office $40.00, specialist $50.00, emergency $250.00
Physical therapy visits: 11 of 20 used

Provider

Billing and rendering

Billing provider: Evergreen Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 5300844821
Network: In network
Rendering NPI: 3851271395
Location: Tempe, AZ · TIN 12-5704558
Authorisation / referral: PA2026630316 / 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	93015	Cardiovascular stress test	—	1	1	$373.00	$205.15	—	—	DeniedCO29
2	93306 rev 0480	Echocardiogram, complete	25	1	2	$1,516.00	$833.80	—	—	DeniedCO29
3	93458 rev 0481	Cardiac catheterisation, left heart	—	1	1	$6,099.00	$3,354.45	—	—	DeniedCO29
Totals						$7,988.00	$4,393.40	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
3. I50.9 Heart failure, unspecified

Claim header

Patient account: PA-278727
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-035339 (verified, link confidence 0.99).
Eligibility	Pass		Active on 2025-11-30: MEDICARE-ADV-A (MA), effective 2025-01-01.
Timely filing	Fail	CO29	Received 200 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		Authorisation PA2026630316 on file for 93458.
Provider network	Pass		In-network provider Evergreen Cardiovascular Associates (5300844821).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Evergreen Cardiovascular Associates2025-11-30 10:54
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
SystemSystem: Claims system2026-06-18 01:24
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-18 14:07
Called the provider office; awaiting documentation.

Attachments

Documents received with the claim

Prior auth letterPA2026630316_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2025-11-30 to 2026-02-28.
Itemized billitemized_PA-278727.pdf6 pages
Itemised statement totalling $7988.00 across 3 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Timely filing: Received 200 days after the last date of service (limit 90).

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

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

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

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

DeniedCO29scenario: Late filing

Received after the timely-filing limit.

Review queue Member identity