CLM-2026-007560
Desert Heart Institute, Cardiology. Service 2026-07-01 at outpatient hospital (POS 22). Received 2026-08-09.
Member
Resolved through the identity graph
- Member
- Becky Williams
- Member ID
- UHC-32568-63
- Date of birth
- 1980-04-20
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-419037
- Relationship
- Self, Charlotte, NC
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-4647
- Coverage period
- 2024-03-01 to present
- Deductible
- $239.43 of $500.0048%
- Out-of-pocket maximum
- $540.66 of $1,500.0036%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 6660182620
- Location
- Mesa, AZ · TIN 39-5178200
- 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 | $590.00 | $324.50 | $273.36 | $51.14 | Paid |
| Totals | $590.00 | $324.50 | $273.36 | $51.14 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-949509
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-001471 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-01: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 39 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 Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2026-07-01 17:59
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-949509.pdf9 pages
Itemised statement totalling $590.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-026106 | 2026-07-24 | Canyon GI Associates | $3,747.00 | Approved |
| CLM-2026-013219 | 2026-02-15 | Sunrise Dermatology Clinic | $163.00 | 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.