CLM-2026-005700
Valley Heart Institute, Cardiology. Service 2026-06-18 at outpatient hospital (POS 22). Received 2026-07-15.
Member
Resolved through the identity graph
- Member
- Timothy Simmons
- Member ID
- UHC-23080-10
- Date of birth
- 1970-01-17
- Identity
- Verified4 records, confidence 1.00
- Claim record
- CLMCLM-430619
- Relationship
- Self, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6856
- Coverage period
- 2024-02-01 to present
- Deductible
- $216.25 of $1,000.0022%
- Out-of-pocket maximum
- $1,400.49 of $3,000.0047%
- Copays
- office $25.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1412691184
- Network
- In network
- Rendering NPI
- 6280089130
- Location
- Atlanta, GA · TIN 70-2461607
- 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 | $412.00 | $226.60 | $226.60 | $0.00 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,474.00 | $810.70 | $633.22 | $177.48 | Paid |
| Totals | $1,886.00 | $1,037.30 | $859.82 | $177.48 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-658581
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-015447 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-06-18: SELECT-EPO (EPO), effective 2024-02-01. | |
| Timely filing | Pass | Received 27 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 Valley Heart Institute (1412691184). | |
| 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 Institute2026-06-18 09:59
Follow-up for unspecified atrial fibrillation. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-658581.pdf5 pages
Itemised statement totalling $1886.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-030914 | 2026-09-12 | Mesa Family Practice | $386.00 | Approved |
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.