CLM-2026-007236
Northgate Heart Institute, Cardiology. Service 2026-03-21 at outpatient hospital (POS 22). Received 2026-04-13.
Member
Resolved through the identity graph
- Member
- Alice Jackson
- Member ID
- UHC-04889-09
- Date of birth
- 1968-01-20
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-418773
- Relationship
- Self, Denver, CO
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-0805
- Coverage period
- 2023-11-01 to 2026-05-20
- Deductible
- $384.37 of $500.0077%
- Out-of-pocket maximum
- $385.17 of $1,000.0039%
- 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
- 5192135197
- Network
- In network
- Rendering NPI
- 3065053415
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- none / REF388917
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 | $433.00 | $238.15 | $127.88 | $110.27 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 2 | $1,211.00 | $666.05 | $66.61 | $599.44 | Paid |
| Totals | $1,644.00 | $904.20 | $194.49 | $709.71 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-587090
- 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-006281 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-03-21: CORE-HMO (HMO), effective 2023-11-01, terms 2026-05-20. | |
| Timely filing | Pass | Received 23 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 (5192135197). | |
| 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: Northgate Heart Institute2026-03-21 16:33
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Itemized billitemized_PA-587090.pdf4 pages
Itemised statement totalling $1644.00 across 2 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
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.