CLM-2026-007950
Riverside Cardiovascular Associates, Cardiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-02-06.
Member
Resolved through the identity graph
- Member
- Cheryl Carr
- Member ID
- UHC-96712-99
- Date of birth
- 1953-08-27
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-412724
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-8312
- Coverage period
- 2025-06-01 to present
- Deductible
- $395.85 of $1,500.0026%
- Out-of-pocket maximum
- $1,649.37 of $6,000.0027%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 9 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 3718409691
- Location
- Atlanta, GA · TIN 37-2658699
- 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 | $1,467.00 | $806.85 | — | — | PendedIDQ |
| Totals | $1,467.00 | $806.85 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I10 Essential (primary) hypertension
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-106930
- 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 | Fail | IDQ | Member record is in open steward case CASE-002533; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-01-08: NULL (PPO), effective 2025-06-01. | |
| Timely filing | Pass | Received 29 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 Riverside Cardiovascular Associates (4236552608). | |
| 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: Riverside Cardiovascular Associates2026-01-08 13:25
Patient seen for chest pain, unspecified.
Attachments
Documents received with the claim
- Itemized billitemized_PA-106930.pdf5 pages
Itemised statement totalling $1467.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-21 13:43Member identity: Member record is in open steward case CASE-002533; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-007951 | 2026-01-08 | Riverside Cardiovascular Associates | $1,467.00 | Denied |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.