CLM-2026-004054
Northgate Heart Institute, Cardiology. Service 2025-11-10 at outpatient hospital (POS 22). Received 2026-06-10.
Member
Resolved through the identity graph
- Member
- Timothy Arnold
- Member ID
- UHC-51075-25
- Date of birth
- 1957-04-13
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-403979
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-6201
- Coverage period
- 2025-02-01 to present
- Deductible
- $198.95 of $500.0040%
- Out-of-pocket maximum
- $74.60 of $1,500.005%
- Copays
- office $40.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 2801087786
- Location
- Los Angeles, CA · TIN 48-8536899
- Authorisation / referral
- none / REF501918
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 | $389.00 | $213.95 | — | — | DeniedCO29 |
| Totals | $389.00 | $213.95 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-428466
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-004054 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-11-10: NAVIGATE-HMO (HMO), effective 2025-02-01. | |
| Timely filing | Fail | CO29 | Received 212 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 | No line requires precertification. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (1929886434). | |
| 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 Institute2025-11-10 14:14
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-06-10 06:43
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
Attachments
Documents received with the claim
- Itemized billitemized_PA-428466.pdf5 pages
Itemised statement totalling $389.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Timely filing: Received 212 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-017928 | 2026-05-16 | Unity Medical Group | $337.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Received after the timely-filing limit.