CLM-2026-005907
Lakeside Heart Institute, Cardiology. Service 2026-06-11 at outpatient hospital (POS 22). Received 2026-06-27.
Member
Resolved through the identity graph
- Member
- Shirley Chavez
- Member ID
- none on golden record
- Date of birth
- 1956-05-14
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-415678
- Relationship
- Self
Coverage and accumulators
Found by name and date of birth
- Plan
- MEDICARE-ADV-B MA group GRP-0224
- Coverage period
- 2021-02-01 to present
- Deductible
- $1,484.02 of $2,500.0059%
- Out-of-pocket maximum
- $2,990.51 of $10,000.0030%
- Copays
- office $20.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8827628438
- Network
- In network
- Rendering NPI
- 6101527615
- Location
- Houston, TX · TIN 99-8948998
- 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 | $459.00 | $252.45 | — | — | PendedIDQ |
| 2 | 93306 rev 0480 | Echocardiogram, complete | 25 | 1 | 1 | $967.00 | $531.85 | — | — | PendedIDQ |
| Totals | $1,426.00 | $784.30 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-738108
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002475; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Note | Active on 2026-06-11: MEDICARE-ADV-B (MA), effective 2021-02-01. Coverage found by name and date of birth because the claim carried no usable member ID. | |
| Timely filing | Pass | Received 16 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 Lakeside Heart Institute (8827628438). | |
| 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: Lakeside Heart Institute2026-06-11 16:43
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-738108.pdf7 pages
Itemised statement totalling $1426.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002475; payment withheld until the identity is confirmed. Eligibility: Active on 2026-06-11: MEDICARE-ADV-B (MA), effective 2021-02-01. Coverage found by name and date of birth because the claim carried no usable member ID.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.