CLM-2026-006587
Unity Cardiovascular Associates, Cardiology. Service 2026-08-10 at outpatient hospital (POS 22). Received 2026-09-22.
Member
Resolved through the identity graph
- Member
- Anna Obrien
- Member ID
- UHC-94402-84
- Date of birth
- 1941-06-20
- Identity
- Verified3 records, confidence 0.97
- Claim record
- CLMCLM-428294
- Relationship
- Spouse, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-5675
- Coverage period
- 2023-06-01 to present
- Deductible
- $128.73 of $1,000.0013%
- Out-of-pocket maximum
- $290.73 of $4,000.007%
- Copays
- office $40.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 1263186193
- Location
- Nashville, TN · TIN 22-5957660
- Authorisation / referral
- PA2026429713 / 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 | $495.00 | $272.25 | $272.25 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 2 | $9,454.00 | $5,199.70 | $1,979.22 | $3,220.48 | Paid |
| 3 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,068.00 | $587.40 | $176.22 | $411.18 | Paid |
| Totals | $11,017.00 | $6,059.35 | $2,427.69 | $3,631.66 | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-797641
- 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-018108 (verified, link confidence 0.97). | |
| Eligibility | Pass | Active on 2026-08-10: SELECT-EPO (EPO), effective 2023-06-01. | |
| Timely filing | Pass | Received 43 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026429713 on file for 93458. | |
| Provider network | Pass | In-network provider Unity Cardiovascular Associates (6971241222). | |
| 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 Associates2026-08-10 15:56
Patient seen for unspecified atrial fibrillation.
Attachments
Documents received with the claim
- Prior auth letterPA2026429713_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-08-10 to 2026-11-08.
- Itemized billitemized_PA-797641.pdf5 pages
Itemised statement totalling $11017.00 across 3 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-2026-005479 | 2026-07-21 | Unity Reference Lab | $143.00 | 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.