CLM-2026-009096
Unity Cardiovascular Associates, Cardiology. Service 2026-05-31 at outpatient hospital (POS 22). Received 2026-06-12.
Member
Resolved through the identity graph
- Member
- Marcus Cook
- Member ID
- UHC-19387-98
- Date of birth
- 1964-01-01
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-431424
- Relationship
- Self, San Diego, CA
Coverage and accumulators
Found by member ID
- Plan
- NAVIGATE-HMO HMO group GRP-7666
- Coverage period
- 2024-11-01 to present
- Deductible
- $300.02 of $2,500.0012%
- Out-of-pocket maximum
- $1,095.64 of $7,500.0015%
- Copays
- office $30.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 6 of 20 used
Provider
Billing and rendering
- Billing provider
- Unity Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 3984509984
- Network
- In network
- Rendering NPI
- 7490093532
- Location
- Austin, TX · TIN 85-7157083
- Authorisation / referral
- none / REF353543
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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $472.00 | $259.60 | $259.60 | $0.00 | Paid |
| Totals | $472.00 | $259.60 | $259.60 | $0.00 | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- 2. I48.91 Unspecified atrial fibrillation
- 3. I50.9 Heart failure, unspecified
- Patient account
- PA-905251
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- 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-002748 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-05-31: NAVIGATE-HMO (HMO), effective 2024-11-01. | |
| Timely filing | Pass | Received 12 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 Unity Cardiovascular Associates (3984509984). | |
| 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: Unity Cardiovascular Associates2026-05-31 17:48
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-06-12 03:05
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-905251.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-905251.pdf7 pages
Itemised statement totalling $472.00 across 1 line.
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-2026-026729 | 2025-11-28 | Pinecrest Cardiovascular Associates | $617.00 | 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
Authorisation must be confirmed with UM before payment.