CLM-2026-009030
Summit Heart Institute, Cardiology. Service 2026-04-26 at outpatient hospital (POS 22). Received 2026-05-20.
Member
Resolved through the identity graph
- Member
- Nancy Carr
- Member ID
- UHC-43731-30
- Date of birth
- 1992-05-05
- Identity
- Verified5 records, confidence 1.00
- Claim record
- CLMCLM-409427
- Relationship
- Self, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-1082
- Coverage period
- 2025-10-01 to present
- Deductible
- $518.15 of $1,000.0052%
- Out-of-pocket maximum
- $239.31 of $4,000.006%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1318552993
- Network
- In network
- Rendering NPI
- 8261585193
- Location
- Tampa, FL · TIN 24-2775289
- Authorisation / referral
- PA2025446836 / REF422430
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 | $5,959.00 | $3,277.45 | $761.41 | $2,516.04 | Paid |
| 2 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $979.00 | $538.45 | $53.85 | $484.60 | Paid |
| Totals | $6,938.00 | $3,815.90 | $815.26 | $3,000.64 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-726257
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-011214 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-04-26: NAVIGATE-HMO (HMO), effective 2025-10-01. | |
| Timely filing | Pass | Received 24 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025446836 on file for 93458. | |
| Provider network | Pass | In-network provider Summit Heart Institute (1318552993). | |
| 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: Summit Heart Institute2026-04-26 15:13
Established patient presents with essential (primary) hypertension; symptoms reviewed and vitals within expected range.
Attachments
Documents received with the claim
- Prior auth letterPA2025446836_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-04-26 to 2026-07-25.
- Itemized billitemized_PA-726257.pdf2 pages
Itemised statement totalling $6938.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-032326 | 2026-02-06 | Meadow Family Practice | $428.00 | Needs review |
| CLM-2026-023069 | 2026-01-13 | Riverside Primary Care Associates | $242.00 | Approved |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.