CLM-2026-006917
Unity Cardiovascular Associates, Cardiology. Service 2026-02-24 at outpatient hospital (POS 22). Received 2026-03-21.
Member
Resolved through the identity graph
- Member
- Debra Ortiz
- Member ID
- UHC-91264-58
- Date of birth
- 1998-11-25
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-406985
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- UNKNOWN PPO group GRP-6609
- Coverage period
- 2022-07-01 to present
- Deductible
- $453.08 of $2,500.0018%
- Out-of-pocket maximum
- $3,705.44 of $7,500.0049%
- Copays
- office $25.00, specialist $60.00, emergency $250.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 4262500752
- Location
- Austin, TX · TIN 85-7157083
- 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 | $679.00 | $373.45 | — | — | Review |
| Totals | $679.00 | $373.45 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-776454
- 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-020089 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-02-24: UNKNOWN (PPO), effective 2022-07-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-006916, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | No line requires precertification. | |
| Provider network | Pass | In-network provider Unity Cardiovascular Associates (3984509984). | |
| 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 Associates2026-02-24 17:09
Patient seen for heart failure, unspecified. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-03-21 01:47
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-03-21 13:51
Member services inquiry logged on this claim; member asked about the status of payment.
Attachments
Documents received with the claim
- Itemized billitemized_PA-776454.pdf6 pages
Itemised statement totalling $679.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Duplicate check: Same member, date of service and procedures as CLM-2026-006916, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-006916 | 2026-02-24 | Sunrise Cardiovascular Associates | $679.00 | 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
Different billing provider; separately payable.