CLM-2026-008688
Lakeside Heart Institute, Cardiology. Service 2026-06-06 at outpatient hospital (POS 22). Received 2026-07-06.
Member
Resolved through the identity graph
- Member
- Heather Vazquez
- Member ID
- UHC-80866-77
- Date of birth
- 1986-11-05
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-418902
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4855
- Coverage period
- 2021-03-01 to present
- Deductible
- $131.54 of $1,000.0013%
- Out-of-pocket maximum
- $614.16 of $3,000.0020%
- Copays
- office $25.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 16 of 20 used
Provider
Billing and rendering
- Billing provider
- Lakeside Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 8827628438
- Network
- In network
- Rendering NPI
- 3110510518
- Location
- Houston, TX · TIN 99-8948998
- 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 | $9,154.00 | $5,034.70 | — | — | DeniedCO197 |
| Totals | $9,154.00 | $5,034.70 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-340097
- 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-003609; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2026-06-06: MEDICARE-ADV-A (MA), effective 2021-03-01. | |
| Timely filing | Pass | Received 30 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 Lakeside Heart Institute (8827628438). | |
| 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: Lakeside Heart Institute2026-06-06 18:54
Patient seen for chest pain, unspecified.
- SystemSystem: Claims system2026-07-06 05:26
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-340097.pdf9 pages
Itemised statement totalling $9154.00 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-003609; 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.