CLM-2026-005313
Unity Cardiovascular Associates, Cardiology. Service 2026-05-08 at outpatient hospital (POS 22). Received 2026-05-21.
Member
Resolved through the identity graph
- Member
- George Patterson
- Member ID
- UHC-34242-48
- Date of birth
- 1983-02-09
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-408592
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4975
- Coverage period
- 2021-07-01 to present
- Deductible
- $1,325.76 of $1,500.0088%
- Out-of-pocket maximum
- $679.83 of $3,000.0023%
- Copays
- office $20.00, specialist $40.00, emergency $250.00
- 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
- 8385667687
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $617.00 | $339.35 | $223.77 | $115.58 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,313.00 | $722.15 | $216.65 | $505.50 | Paid |
| Totals | $1,930.00 | $1,061.50 | $440.42 | $621.08 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-114415
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005856 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-08: OPTIONS-PPO (PPO), effective 2021-07-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | No line requires precertification. | |
| 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 Associates2026-05-08 18:13
Patient seen for heart failure, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-114415.pdf3 pages
Itemised statement totalling $1930.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033048 | 2026-06-10 | Cornerstone Internal Medicine Associates | $307.00 | Approved |
| CLM-2026-025058 | 2025-12-06 | Harbor Bone and Joint Center | $50,006.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.