CLM-2026-004424
Unity Cardiovascular Associates, Cardiology. Service 2026-03-15 at outpatient hospital (POS 22). Received 2026-03-18.
Member
Resolved through the identity graph
- Member
- Tyler Washington
- Member ID
- UHC-77864-45
- Date of birth
- 1941-08-11
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-428417
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- - PPO group GRP-0847
- Coverage period
- 2022-04-01 to present
- Deductible
- $39.18 of $1,500.003%
- Out-of-pocket maximum
- $1,047.81 of $3,000.0035%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 4451999609
- Location
- Austin, TX · TIN 85-7157083
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,275.00 | $4,551.25 | — | — | DeniedCO197 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1,2 | $443.00 | $243.65 | — | — | DeniedCO197 |
| 3 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1,2 | $1,485.00 | $816.75 | — | — | DeniedCO197 |
| Totals | $10,203.00 | $5,611.65 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-489992
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-020415 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-03-15: - (PPO), effective 2022-04-01. | |
| Timely filing | Pass | Received 3 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Unity Cardiovascular Associates (3984509984). | |
| 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: Unity Cardiovascular Associates2026-03-15 14:58
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-03-18 06:12
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-489992.pdf6 pages
Itemised statement totalling $10203.00 across 3 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.