CLM-2026-008935
Desert Heart Institute, Cardiology. Service 2026-06-22 at outpatient hospital (POS 22). Received 2026-07-07.
Member
Resolved through the identity graph
- Member
- Jeremy Wong
- Member ID
- UHC-88270-98
- Date of birth
- 1939-09-08
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-423152
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- SELECT-EPO EPO group GRP-6987
- Coverage period
- 2023-09-01 to 2026-02-23
- Deductible
- $788.93 of $1,000.0079%
- Out-of-pocket maximum
- $162.41 of $2,000.008%
- Copays
- office $20.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 2245842762
- Location
- Mesa, AZ · TIN 39-5178200
- 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 | $964.00 | $530.20 | — | — | DeniedCO27 |
| Totals | $964.00 | $530.20 | — | — | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-505366
- 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-022832 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-06-22 is after coverage terminated on 2026-02-23. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 15 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 Heart Institute (5901282678). | |
| 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 Heart Institute2026-06-22 09:44
Established patient presents with heart failure, unspecified; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-07 06:29
Attachments
Documents received with the claim
- Itemized billitemized_PA-505366.pdf6 pages
Itemised statement totalling $964.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-06-22 is after coverage terminated on 2026-02-23.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-029403 | 2026-02-28 | Sunrise Imaging Center | $2,273.00 | 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.