CLM-2026-003185
Evergreen Cardiovascular Associates, Cardiology. Service 2026-06-28 at outpatient hospital (POS 22). Received 2026-07-10.
Member
Resolved through the identity graph
- Member
- Carlos McCoy
- Member ID
- none on golden record
- Date of birth
- 1981-10-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-417658
- Relationship
- Self, Tampa, FL
Coverage and accumulators
Eligibility
Provider
Billing and rendering
- Billing provider
- Evergreen Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5300844821
- Network
- In network
- Rendering NPI
- 3614760809
- Location
- Tempe, AZ · TIN 12-5704558
- Authorisation / referral
- PA2026396931 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $9,136.00 | $5,024.80 | — | — | PendedIDQ |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $383.00 | $210.65 | — | — | PendedIDQ |
| Totals | $9,519.00 | $5,235.45 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-190119
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-001734; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Fail | N30 | No coverage segment found for the member ID on this claim. Patient ineligible for this service |
| Timely filing | Pass | Received 12 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026396931 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. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Evergreen Cardiovascular Associates2026-06-28 17:35
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2026396931_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-06-28 to 2026-09-26.
- Itemized billitemized_PA-190119.pdf9 pages
Itemised statement totalling $9519.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-001734; payment withheld until the identity is confirmed. Eligibility: No coverage segment found for the member ID on this claim.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.