CLM-2026-009723
Northgate Heart Institute, Cardiology. Service 2026-05-30 at outpatient hospital (POS 22). Received 2026-07-04.
Member
Resolved through the identity graph
- Member
- Brian Reid
- Member ID
- UHC-22030-18
- Date of birth
- 1972-04-13
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-409706
- Relationship
- Spouse, Orlando, FL
Coverage and accumulators
Found by member ID
- Plan
- CHOICE-PLUS-PPO PPO group GRP-1355
- Coverage period
- 2025-01-01 to present
- Deductible
- $1,756.30 of $2,500.0070%
- Out-of-pocket maximum
- $2,295.82 of $10,000.0023%
- Copays
- office $20.00, specialist $75.00, emergency $250.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 3287321483
- Location
- Los Angeles, CA · TIN 48-8536899
- 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 | $461.00 | $253.55 | — | — | DeniedCO197 |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1,2 | $6,687.00 | $3,677.85 | — | — | DeniedCO197 |
| Totals | $7,148.00 | $3,931.40 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-517216
- 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-003645 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-05-30: CHOICE-PLUS-PPO (PPO), effective 2025-01-01. | |
| Timely filing | Pass | Received 35 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Fail | CO197 | 93458 require precertification; no authorisation number on the claim. Precertification or authorization absent |
| Provider network | Pass | In-network provider Northgate Heart Institute (1929886434). | |
| 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: Northgate Heart Institute2026-05-30 16:04
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range.
- SystemSystem: Claims system2026-07-04 01:47
Procedure requires precertification; no authorisation number on the claim and none found in the UM system.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-07-04 13:29
Reviewed with the member's history on file. Holding for the items listed above.
Attachments
Documents received with the claim
- Itemized billitemized_PA-517216.pdf4 pages
Itemised statement totalling $7148.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineDenied2026-10-21 13:43Prior authorisation: 93458 require precertification; no authorisation number on the claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-005844 | 2026-06-06 | Unity Digestive Health Center | $266.00 | Approved |
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
Precertification required and absent.