CLM-2026-007538
Lakeside Heart Institute, Cardiology. Service 2026-01-29 at outpatient hospital (POS 22). Received 2026-02-12.
Member
Resolved through the identity graph
- Member
- Doris Ford
- Member ID
- UHC-97244-05
- Date of birth
- 1958-02-28
- Identity
- Verified4 records, confidence 0.94
- Claim record
- CLMCLM-424925
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2427
- Coverage period
- 2023-03-01 to 2026-01-12
- Deductible
- $299.09 of $500.0060%
- Out-of-pocket maximum
- $664.32 of $1,500.0044%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8827628438
- Network
- In network
- Rendering NPI
- 6410628690
- Location
- Houston, TX · TIN 99-8948998
- 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 | $1,178.00 | $647.90 | — | — | DeniedCO27 |
| Totals | $1,178.00 | $647.90 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. R07.9 Chest pain, unspecified
- Patient account
- PA-851670
- 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-012620 (verified, link confidence 0.94). | |
| Eligibility | Fail | CO27 | Date of service 2026-01-29 is after coverage terminated on 2026-01-12. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 14 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 Lakeside Heart Institute (8827628438). | |
| 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: Lakeside Heart Institute2026-01-29 11:10
Patient seen for essential (primary) hypertension.
- SystemSystem: Claims system2026-02-12 00:47
Attachments
Documents received with the claim
- Itemized billitemized_PA-851670.pdf7 pages
Itemised statement totalling $1178.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-01-29 is after coverage terminated on 2026-01-12.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-027675 | 2026-07-19 | Riverside Imaging Center | $450.00 | Denied |
| CLM-2026-019764 | 2026-03-17 | Mesa Medical Group | $25.00 | 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.