CLM-2026-005683
Summit Cardiovascular Associates, Cardiology. Service 2026-09-12 at office (POS 11). Received 2026-09-25.
Member
Resolved through the identity graph
- Member
- Robert Ross
- Member ID
- UHC-39201-16
- Date of birth
- 1997-08-18
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-405236
- Relationship
- Self, Gilbert, AZ
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7518
- Coverage period
- 2025-10-01 to present
- Deductible
- $2,057.67 of $2,500.0082%
- Out-of-pocket maximum
- $619.50 of $10,000.006%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 10 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 1052687831
- Location
- Houston, TX · TIN 53-6389420
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $379.00 | $234.98 | — | — | DeniedCO18 |
| Totals | $379.00 | $234.98 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-822048
- 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-008813 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-09-12: NULL (PPO), effective 2025-10-01. | |
| Timely filing | Pass | Received 13 days after service (limit 90). | |
| Duplicate check | Fail | CO18 | Exact duplicate of CLM-2026-005682: same member, date of service, procedures and billing provider. Exact duplicate claim or service |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Summit Cardiovascular Associates (5138686964). | |
| 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 Cardiovascular Associates2026-09-12 10:10
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-09-25 04:13
System edit 018 fired: identical member, date of service, procedure and billing provider as a prior submission.
- AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-09-25 15:52
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Duplicate check: Exact duplicate of CLM-2026-005682: same member, date of service, procedures and billing provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005682 | 2026-09-12 | Summit Cardiovascular Associates | $379.00 | Approved |
| CLM-2026-026967 | 2026-01-27 | Lakeside Reference Lab | $162.00 | 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
Exact duplicate of an earlier submission.