CLM-2026-006590
Northgate Heart Institute, Cardiology. Service 2026-05-04 at office (POS 11). Received 2026-06-04.
Member
Resolved through the identity graph
- Member
- Michelle Carroll
- Member ID
- UHC-10245-69
- Date of birth
- 1980-12-26
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418520
- Relationship
- Self, San Antonio, TX
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0377
- Coverage period
- 2022-07-01 to present
- Deductible
- $368.71 of $2,500.0015%
- Out-of-pocket maximum
- $1,033.19 of $7,500.0014%
- Copays
- office $40.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 7130389415
- Location
- Los Angeles, CA · TIN 48-8536899
- Authorisation / referral
- none / REF205065
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 | 99214 | Office visit, established patient, moderate complexity | — | 1 | 1 | $230.00 | $142.60 | — | — | Review |
| Totals | $230.00 | $142.60 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-965456
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-018690 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-04: CORE-HMO (HMO), effective 2022-07-01. | |
| Timely filing | Pass | Received 31 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 Northgate Heart Institute (1929886434). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Northgate Heart Institute2026-05-04 18:38
Patient seen for chest pain, unspecified. Note dictated; signature pending.
- SystemSystem: Claims system2026-06-04 04:29
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-06-04 08:48
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for chest pain, unspecified. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-001061 | 2026-02-22 | Sunrise Imaging Center | $4,985.00 | Approved |
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
Development letter outstanding.