CLM-2026-007428
Northgate Cardiovascular Associates, Cardiology. Service 2026-08-07 at outpatient hospital (POS 22). Received 2026-08-12.
Member
Resolved through the identity graph
- Member
- Roger Martinez
- Member ID
- UHC-40330-54
- Date of birth
- 1990-03-15
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-432490
- Relationship
- Spouse, Phoenix, AZ
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-9256
- Coverage period
- 2024-09-01 to present
- Deductible
- $350.33 of $500.0070%
- Out-of-pocket maximum
- $172.97 of $1,500.0012%
- Copays
- office $30.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5594465275
- Network
- In network
- Rendering NPI
- 8293448667
- Location
- Los Angeles, CA · TIN 22-8335037
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,455.00 | $800.25 | $344.84 | $455.41 | Paid |
| 2 | 93015 | Cardiovascular stress test | — | 1 | 1 | $693.00 | $381.15 | $114.34 | $266.81 | Paid |
| Totals | $2,148.00 | $1,181.40 | $459.18 | $722.22 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-833026
- 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-004988 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-08-07: SELECT-EPO (EPO), effective 2024-09-01. | |
| Timely filing | Pass | Received 5 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 Cardiovascular Associates (5594465275). | |
| 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 Cardiovascular Associates2026-08-07 18:30
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-833026.pdf3 pages
Itemised statement totalling $2148.00 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
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-010891 | 2025-10-29 | Pinecrest Regional Medical Center | $970.00 | Denied |
| CLM-2026-025512 | 2026-04-05 | Mesa Physical Therapy | $624.00 | Approved |
| CLM-2026-024487 | 2025-12-15 | Summit Digestive Health Center | $1,740.00 | 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.