CLM-2026-007778
Desert Cardiovascular Associates, Cardiology. Service 2026-07-24 at outpatient hospital (POS 22). Received 2026-08-26.
Member
Resolved through the identity graph
- Member
- Susan Hamilton
- Member ID
- UHC-49973-47
- Date of birth
- 1983-12-09
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-428700
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-7961
- Coverage period
- 2022-09-01 to 2026-06-01
- Deductible
- $1,657.80 of $3,500.0047%
- Out-of-pocket maximum
- $308.48 of $7,000.004%
- Copays
- office $30.00, specialist $60.00, emergency $150.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1421288352
- Network
- In network
- Rendering NPI
- 6191120131
- Location
- Houston, TX · TIN 63-6537518
- 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 | $1,098.00 | $603.90 | — | — | DeniedCO27 |
| Totals | $1,098.00 | $603.90 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-648487
- 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-000414 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-07-24 is after coverage terminated on 2026-06-01. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 33 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 Cardiovascular Associates (1421288352). | |
| 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 Cardiovascular Associates2026-07-24 10:22
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-08-26 00:58
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-08-26 17:20
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-648487.pdf2 pages
Itemised statement totalling $1098.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-07-24 is after coverage terminated on 2026-06-01.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007841 | 2026-08-06 | Northgate Internal Medicine Associates | $358.00 | 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.