CLM-2026-009638
Mesa Cardiovascular Associates, Cardiology. Service 2026-03-08 at outpatient hospital (POS 22). Received 2026-03-11.
Member
Resolved through the identity graph
- Member
- Jesse Fowler
- Member ID
- UHC-13704-87
- Date of birth
- 1998-12-11
- Identity
- Verified3 records, confidence 0.99
- Claim record
- CLMCLM-404654
- Relationship
- Spouse, Miami, FL
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-3861
- Coverage period
- 2023-10-01 to 2026-02-27
- Deductible
- $812.44 of $1,500.0054%
- Out-of-pocket maximum
- $1,258.03 of $3,000.0042%
- Copays
- office $20.00, specialist $75.00, emergency $350.00
- Physical therapy visits
- 12 of 20 used
Provider
Billing and rendering
- Billing provider
- Mesa Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4876629211
- Network
- In network
- Rendering NPI
- 2838410191
- Location
- Austin, TX · TIN 24-4510825
- Authorisation / referral
- none / REF188264
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 | $552.00 | $303.60 | — | — | DeniedCO27 |
| Totals | $552.00 | $303.60 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-871938
- 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-010318 (verified, link confidence 0.99). | |
| Eligibility | Fail | CO27 | Date of service 2026-03-08 is after coverage terminated on 2026-02-27. Expenses incurred after coverage terminated |
| Timely filing | Pass | Received 3 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 Mesa Cardiovascular Associates (4876629211). | |
| 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: Mesa Cardiovascular Associates2026-03-08 12:34
Follow-up for atherosclerotic heart disease of native coronary artery without angina. Plan discussed, medications reconciled.
- SystemSystem: Claims system2026-03-11 05:30
Attachments
Documents received with the claim
- Itemized billitemized_PA-871938.pdf5 pages
Itemised statement totalling $552.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Eligibility: Date of service 2026-03-08 is after coverage terminated on 2026-02-27.
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
Service after coverage termination.