CLM-2026-002855
Northgate Heart Institute, Cardiology. Service 2026-06-01 at outpatient hospital (POS 22). Received 2026-07-16.
Member
Resolved through the identity graph
- Member
- Janet Boyd
- Member ID
- UHC-81858-35
- Date of birth
- 1976-01-03
- Identity
- Verified5 records, confidence 0.90
- Claim record
- CLMCLM-407203
- Relationship
- Self, Nashville, TN
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-6378
- Coverage period
- 2021-06-01 to present
- Deductible
- $1,525.18 of $3,500.0044%
- Out-of-pocket maximum
- $196.15 of $7,000.003%
- Copays
- office $30.00, specialist $40.00, emergency $350.00
- 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
- 4418759104
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $603.00 | $331.65 | $331.65 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,512.00 | $831.60 | $831.60 | $0.00 | Paid |
| Totals | $2,115.00 | $1,163.25 | $1,163.25 | $0.00 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-263673
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-014592 (verified, link confidence 0.90). | |
| Eligibility | Pass | Active on 2026-06-01: CHOICE-PLUS-PPO (PPO), effective 2021-06-01. | |
| Timely filing | Pass | Received 45 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 Institute2026-06-01 18:40
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-263673.pdf8 pages
Itemised statement totalling $2115.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-028698 | 2026-02-17 | Mesa Medical Group | $1,914.00 | Needs review |
| CLM-2026-021859 | 2025-11-07 | Pinecrest Bone and Joint Center | $49,998.00 | 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.