Claims workbench/CLM-2026-004114
Institutional claim · UB-04 · EDI 837I

CLM-2026-004114

Unity Cardiovascular Associates, Cardiology. Service 2026-02-21 at outpatient hospital (POS 22). Received 2026-03-30.

Pended
Billed
$9,311.00
1 line
Allowed
$5,121.05
if approved
Plan pays
—
Pended
Member owes
—
no coverage
Rules engine
Pend
CO16, N30
Decided by
Claims rules engine
2026-10-21 13:43

Member

Resolved through the identity graph

The claim record could not be attached to a resolved identity. Resolve it in the steward queue first.

Coverage and accumulators

Eligibility

No coverage segment found for this member.

Provider

Billing and rendering

Billing provider
Unity Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI
3984509984
Network
In network
Rendering NPI
1372302913
Location
Austin, TX · TIN 85-7157083
Authorisation / referral
PA2026839337 / REF765492

Service lines

UB-04: procedures, modifiers, units, charges and the pricing outcome per line

LineCodeDescriptionMod.UnitsDxBilledAllowedMemberPlanLine status
193458
rev 0481
Cardiac catheterisation, left heart—11$9,311.00$5,121.05——PendedCO16
Totals$9,311.00$5,121.05——
Diagnoses (ICD-10-CM)
  • 1. R07.9 Chest pain, unspecifiedprincipal
  • 2. I50.9 Heart failure, unspecified
Claim header
Patient account
PA-134308
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

CheckResultCodeDetail
Member identityFailCO16Claim record is not attached to a resolved identity.
Claim lacks information needed for adjudication
EligibilityFailN30No coverage segment found for the member ID on this claim.
Patient ineligible for this service
Timely filingPassReceived 37 days after service (limit 90).
Duplicate checkPassNo matching prior claim in the duplicate window.
Prior authorisationPassAuthorisation PA2026839337 on file for 93458.
Provider networkPassIn-network provider Unity Cardiovascular Associates (3984509984).
Medical necessityPassDiagnosis supports the procedures billed.
Bundling (NCCI)PassNo bundling conflicts.
Benefit limitsPassNo limited benefit on this claim.
CompletenessPassRequired documentation present.
High-dollar reviewPassWithin the auto-adjudication ceiling.
Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Pended.

Notes

Provider, system and examiner notes on this claim

  • ClinicalProvider: Unity Cardiovascular Associates2026-02-21 10:11

    Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.

Attachments

Documents received with the claim

  • Prior auth letterPA2026839337_approval.pdf2 pages

    Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-21 to 2026-05-22.

  • Itemized billitemized_PA-134308.pdf5 pages

    Itemised statement totalling $9311.00 across 1 line.

Claim history

Every event on this claim, sealed in the audit chain

  1. Rules enginePended2026-10-21 13:43
    Member identity: Claim record is not attached to a resolved identity. Eligibility: No coverage segment found for the member ID on this claim.

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

Record the final decision; pricing and remittance reasons follow from it

Outcome
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

Approvedscenario: Clean

Clean claim, priced at contract rate.

Review queue