CLM-2026-007960
Valley Cardiovascular Associates, Cardiology. Service 2026-09-11 at outpatient hospital (POS 22). Received 2026-10-10.
Member
Resolved through the identity graph
- Member
- Jordan Richards
- Member ID
- UHC-99630-40
- Date of birth
- 1964-04-15
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-406363
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-7360
- Coverage period
- 2023-11-01 to present
- Deductible
- $443.51 of $500.0089%
- Out-of-pocket maximum
- $254.29 of $1,000.0025%
- Copays
- office $30.00, specialist $50.00, emergency $250.00
- Physical therapy visits
- 15 of 20 used
Provider
Billing and rendering
- Billing provider
- Valley Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4553481845
- Network
- In network
- Rendering NPI
- 2233210667
- Location
- Dallas, TX · TIN 18-8856969
- 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $8,484.00 | $4,666.20 | — | — | DeniedCO197 |
| Totals | $8,484.00 | $4,666.20 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-774124
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 2 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002898; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-09-11: OPTIONS-PPO (PPO), effective 2023-11-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Valley Cardiovascular Associates (4553481845). | |
| 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: Valley Cardiovascular Associates2026-09-11 12:40
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-10-10 04:04
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
Attachments
Documents received with the claim
- Itemized billitemized_PA-774124.pdf5 pages
Itemised statement totalling $8484.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Member identity: Member record is in open steward case CASE-002898; payment withheld until the identity is confirmed. Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
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
Precertification required and absent.