CLM-2026-005676
Riverside Cardiovascular Associates, Cardiology. Service 2026-04-05 at outpatient hospital (POS 22). Received 2026-05-03.
Member
Resolved through the identity graph
- Member
- Jordan Burton
- Member ID
- UHC-73034-90
- Date of birth
- 1954-08-28
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-402102
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3788
- Coverage period
- 2024-06-01 to present
- Deductible
- $194.11 of $500.0039%
- Out-of-pocket maximum
- $948.57 of $2,000.0047%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 21 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 6323885171
- Location
- Atlanta, GA · TIN 37-2658699
- Authorisation / referral
- none / REF437689
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 | $1,516.00 | $833.80 | $411.47 | $422.33 | Paid |
| Totals | $1,516.00 | $833.80 | $411.47 | $422.33 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I10 Essential (primary) hypertension
- Patient account
- PA-477371
- 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-002691 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-04-05: CORE-HMO (HMO), effective 2024-06-01. | |
| Timely filing | Pass | Received 28 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 Riverside Cardiovascular Associates (4236552608). | |
| 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: Riverside Cardiovascular Associates2026-04-05 10:09
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-477371.pdf5 pages
Itemised statement totalling $1516.00 across 1 line.
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-2026-023467 | 2026-10-02 | Heritage Community Hospital | $3,859.00 | Approved |
| CLM-2026-027320 | 2026-04-01 | Mesa Orthopedic Specialists | $260.00 | Denied |
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.