CLM-2026-005007
Summit Heart Institute, Cardiology. Service 2025-11-08 at outpatient hospital (POS 22). Received 2026-03-02.
Member
Resolved through the identity graph
- Member
- Jennifer Castro
- Member ID
- UHC-02041-85
- Date of birth
- 1950-04-02
- Identity
- Verified4 records, confidence 0.96
- Claim record
- CLMCLM-425658
- Relationship
- Self, Jacksonville, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1653
- Coverage period
- 2021-05-01 to present
- Deductible
- $138.45 of $2,500.006%
- Out-of-pocket maximum
- $177.50 of $7,500.002%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 17 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 9298410728
- Location
- Tampa, FL · TIN 24-2775289
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,526.00 | $839.30 | — | — | DeniedCO29 |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 2 | $534.00 | $293.70 | — | — | DeniedCO29 |
| Totals | $2,060.00 | $1,133.00 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-257087
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005253 (verified, link confidence 0.96). | |
| Eligibility | Pass | Active on 2025-11-08: CHOICE-PLUS-PPO (PPO), effective 2021-05-01. | |
| Timely filing | Fail | CO29 | Received 114 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 Summit Heart Institute (1318552993). | |
| 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: Summit Heart Institute2025-11-08 18:36
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-03-02 00:49
Received more than 90 days after the last date of service. Check for a timely-filing waiver before finalising.
- AdministrativeExaminer: D. Okafor (Medical Director, MD)2026-03-02 09:18
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-257087.pdf9 pages
Itemised statement totalling $2060.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Timely filing: Received 114 days after the last date of service (limit 90).
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-019147 | 2026-02-20 | Northgate Counseling Center | $443.00 | Denied |
| CLM-2026-019146 | 2026-02-20 | Northgate Counseling Center | $443.00 | 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.