CLM-2026-004716
Valley Heart Institute, Cardiology. Service 2026-02-20 at outpatient hospital (POS 22). Received 2026-03-17.
Member
Resolved through the identity graph
- Member
- Sophia Carroll
- Member ID
- none on golden record
- Date of birth
- 1979-02-23
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406609
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-7932
- Coverage period
- 2023-12-01 to 2026-03-12
- Deductible
- $962.16 of $2,500.0038%
- Out-of-pocket maximum
- $1,728.42 of $5,000.0035%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 9412184639
- Network
- In network
- Rendering NPI
- 4290643673
- Location
- Mesa, AZ · TIN 29-6624105
- Authorisation / referral
- PA2026111114 / 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 | $5,899.00 | $3,244.45 | — | — | PendedIDQ |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,304.00 | $717.20 | — | — | PendedIDQ |
| Totals | $7,203.00 | $3,961.65 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-416862
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
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-003009; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-02-20: MEDICARE-ADV-B (MA), effective 2023-12-01, terms 2026-03-12. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026111114 on file for 93458. | |
| Provider network | Pass | In-network provider Valley Heart Institute (9412184639). | |
| 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: Valley Heart Institute2026-02-20 16:15
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Prior auth letterPA2026111114_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-02-20 to 2026-05-21.
- Itemized billitemized_PA-416862.pdf6 pages
Itemised statement totalling $7203.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-003009; payment withheld until the identity is confirmed. Eligibility: Active on 2026-02-20: MEDICARE-ADV-B (MA), effective 2023-12-01, terms 2026-03-12. Coverage found by name and date of birth because the claim carried no usable member ID.
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.