CLM-2026-007770
Evergreen Cardiovascular Associates, Cardiology. Service 2026-09-12 at outpatient hospital (POS 22). Received 2026-09-29.
Member
Resolved through the identity graph
- Member
- Grace Hicks
- Member ID
- UHC-28983-41
- Date of birth
- 1993-10-19
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423728
- Relationship
- Child, Fresno, CA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group N/A
- Coverage period
- 2024-03-01 to present
- Deductible
- $1,143.85 of $3,500.0033%
- Out-of-pocket maximum
- $1,884.31 of $10,500.0018%
- Copays
- office $40.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Evergreen Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5300844821
- Network
- In network
- Rendering NPI
- 6395996187
- Location
- Tempe, AZ · TIN 12-5704558
- Authorisation / referral
- PA2026325080 / 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 | $484.00 | $266.20 | $266.20 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,242.00 | $2,883.10 | $2,248.58 | $634.52 | Paid |
| Totals | $5,726.00 | $3,149.30 | $2,514.78 | $634.52 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I50.9 Heart failure, unspecified
- 3. I25.10 Atherosclerotic heart disease of native coronary artery without angina
- Patient account
- PA-114810
- 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-043312 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-12: OPTIONS-PPO (PPO), effective 2024-03-01. | |
| Timely filing | Pass | Received 17 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026325080 on file for 93458. | |
| Provider network | Pass | In-network provider Evergreen Cardiovascular Associates (5300844821). | |
| 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: Evergreen Cardiovascular Associates2026-09-12 17:49
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Prior auth letterPA2026325080_approval.pdf2 pages
Utilisation management approval letter for 93015 (Cardiovascular stress test), valid 2026-09-12 to 2026-12-11.
- Itemized billitemized_PA-114810.pdf6 pages
Itemised statement totalling $5726.00 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-2026-010261 | 2026-09-08 | Mesa Family Practice | $289.00 | 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.