CLM-2026-009452
Riverside Cardiovascular Associates, Cardiology. Service 2025-12-25 at outpatient hospital (POS 22). Received 2026-01-31.
Member
Resolved through the identity graph
- Member
- Emily Diaz
- Member ID
- UHC-27713-43
- Date of birth
- 1962-04-24
- Identity
- Provisional1 records, confidence 1.00
- Claim record
- CLMCLM-416651
- Relationship
- Self
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group UNKNOWN
- Coverage period
- 2023-02-01 to present
- Deductible
- $802.01 of $1,000.0080%
- Out-of-pocket maximum
- $474.29 of $3,000.0016%
- Copays
- office $40.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 2 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 7826654882
- Location
- Atlanta, GA · TIN 37-2658699
- 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 | 93015 | Cardiovascular stress test | — | 1 | 1 | $481.00 | $264.55 | — | — | PendedIDQ |
| Totals | $481.00 | $264.55 | — | — | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- 2. I48.91 Unspecified atrial fibrillation
- Patient account
- PA-131622
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Fail | IDQ | Member record is in open steward case CASE-002186; payment withheld until the identity is confirmed. Member identity under steward review |
| Eligibility | Pass | Active on 2025-12-25: CHOICE-PLUS-PPO (PPO), effective 2023-02-01. | |
| Timely filing | Pass | Received 37 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 Riverside Cardiovascular Associates (4236552608). | |
| 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: Riverside Cardiovascular Associates2025-12-25 10:53
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Itemized billitemized_PA-131622.pdf9 pages
Itemised statement totalling $481.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules enginePended2026-10-22 12:44Member identity: Member record is in open steward case CASE-002186; payment withheld until the identity is confirmed.
Other claims for this member
Same resolved identity
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Record the final decision; pricing and remittance reasons follow from it
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.