CLM-2026-007481
Unity Cardiovascular Associates, Cardiology. Service 2026-07-26 at outpatient hospital (POS 22). Received 2026-07-31.
Member
Resolved through the identity graph
- Member
- Keith Silva
- Member ID
- UHC-11375-71
- Date of birth
- 1987-02-11
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-424798
- Relationship
- Child, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group UNKNOWN
- Coverage period
- 2024-06-01 to 2026-06-18
- Deductible
- $467.10 of $2,500.0019%
- Out-of-pocket maximum
- $1,040.82 of $7,500.0014%
- Copays
- office $20.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 7 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 6971241222
- Network
- In network
- Rendering NPI
- 7104638987
- Location
- Nashville, TN · TIN 22-5957660
- 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 | $617.00 | $339.35 | — | — | DeniedCO27 |
| Totals | $617.00 | $339.35 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-903086
- 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-038893 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-26 is after coverage terminated on 2026-06-18. Expenses incurred after coverage terminated |
| 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 Unity Cardiovascular Associates (6971241222). | |
| 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 Associates2026-07-26 17:41
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-07-31 04:16
Attachments
Documents received with the claim
- Itemized billitemized_PA-903086.pdf6 pages
Itemised statement totalling $617.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-22 12:44Eligibility: Date of service 2026-07-26 is after coverage terminated on 2026-06-18.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-013011 | 2026-07-20 | Desert Internal Medicine Associates | $200.00 | Denied |
| CLM-2026-013677 | 2026-07-17 | Meadow Clinical Laboratories | $1,890.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Denied by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Service after coverage termination.