Claims workbench/CLM-2026-007198

Institutional claim · UB-04 · Provider portal

CLM-2026-007198

Northgate Cardiovascular Associates, Cardiology. Service 2026-06-16 at outpatient hospital (POS 22). Received 2026-07-01.

Needs review

Billed

$9,303.00

2 lines

Allowed

$5,116.65

if approved

Plan pays

—

Needs review

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Review

CO97

Decided by

Nobody yet

open

Member

Resolved through the identity graph

Member: Thomas Carter
Member ID: UHC-18931-33
Date of birth: 1984-12-06
Identity: Verified5 records, confidence 0.97
Claim record: CLMCLM-420429
Relationship: Child, Glendale, AZ

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-5519
Coverage period: 2022-02-01 to present
Deductible: $414.26 of $500.0083%
Out-of-pocket maximum: $147.04 of $1,500.0010%
Copays: office $25.00, specialist $40.00, emergency $250.00
Physical therapy visits: 18 of 20 used

Provider

Billing and rendering

Billing provider: Northgate Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 7788544188
Network: In network
Rendering NPI: 8825156663
Location: Denver, CO · TIN 90-6939418
Authorisation / referral: PA2025793791 / 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	93306 rev 0480	Echocardiogram, complete	59	1	1	$1,547.00	$850.85	—	—	Review
2	93458 rev 0481	Cardiac catheterisation, left heart	59	1	1,2	$7,756.00	$4,265.80	—	—	Review
Totals						$9,303.00	$5,116.65	—	—

Diagnoses (ICD-10-CM)

1. I48.91 Unspecified atrial fibrillationprincipal
2. R07.9 Chest pain, unspecified

Claim header

Patient account: PA-225102
Frequency code: 1 (original)
Accident: No
DRG: —
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 1 needing attention

Check	Result	Code	Detail
Member identity	Pass		Attached to MBR-005273 (verified, link confidence 0.97).
Eligibility	Pass		Active on 2026-06-16: MEDICARE-ADV-A (MA), effective 2022-02-01.
Timely filing	Pass		Received 15 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025793791 on file for 93458.
Provider network	Pass		In-network provider Northgate Cardiovascular Associates (7788544188).
Medical necessity	Pass		Diagnosis supports the procedures billed.
Bundling (NCCI)	Review	CO97	Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service. Benefit included in another service already adjudicated
Benefit limits	Pass		No limited benefit on this claim.
Completeness	Pass		Required documentation present.
High-dollar review	Pass		Within the auto-adjudication ceiling.

Evaluated 2026-10-21 13:43 under policy version 1. Left for review: soft signals only, no hard rule fired.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Northgate Cardiovascular Associates2026-06-16 18:48
Patient seen for unspecified atrial fibrillation. Both procedures were performed at the same site during the same session as part of one service.
SystemSystem: Claims system2026-07-01 05:25
NCCI edit: modifier 59 used on a code pair that is normally bundled. Operative note requested.

Attachments

Documents received with the claim

Prior auth letterPA2025793791_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-06-16 to 2026-09-14.
Itemized billitemized_PA-225102.pdf6 pages
Itemised statement totalling $9303.00 across 2 lines.
Medical recordrecords_PA-225102.pdf15 pages
Operative note describes a single procedure at one site; no separate session.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineReview2026-10-21 13:43
Bundling (NCCI): Modifier 59 used on a normally bundled code pair; the operative note must document a distinct procedural service.

Other claims for this member

Same resolved identity

Claim	Service	Provider	Billed	Status
CLM-2026-005948	2026-06-18	Sunrise Community Hospital	$2,660.00	Approved
CLM-2026-015509	2026-06-03	Northgate Internal Medicine Associates	$303.00	Approved
CLM-2026-001411	2025-12-18	Sunrise Imaging Center	$2,098.00	Approved

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

The rules engine left this claim for review. The AI adjudicator can read the evidence pack (lines, notes, attachments, coverage, history) and recommend an outcome with citations.

Examiner decision

Record the final decision; pricing and remittance reasons follow from it

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO97scenario: Unbundling

Bundled code pair; modifier 59 not supported by the operative note.

Review queue Member identity