CLM-2026-009725
Riverside Cardiovascular Associates, Cardiology. Service 2025-12-26 at outpatient hospital (POS 22). Received 2026-01-18.
Member
Resolved through the identity graph
- Member
- Joshua Gibson
- Member ID
- UHC-80149-44
- Date of birth
- 1987-11-05
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-427569
- Relationship
- Self, Tempe, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-4546
- Coverage period
- 2021-04-01 to present
- Deductible
- $323.11 of $1,000.0032%
- Out-of-pocket maximum
- $1,488.02 of $4,000.0037%
- Copays
- office $20.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 13 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 6501304516
- 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 | $694.00 | $381.70 | $381.70 | $0.00 | Paid |
| Totals | $694.00 | $381.70 | $381.70 | $0.00 | ||||||
- 1. I50.9 Heart failure, unspecifiedprincipal
- Patient account
- PA-745039
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005434 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-26: MEDICARE-ADV-A (MA), effective 2021-04-01. | |
| Timely filing | Pass | Received 23 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 Associates2025-12-26 12:41
Follow-up for heart failure, unspecified. Plan discussed, medications reconciled.
Attachments
Documents received with the claim
- Itemized billitemized_PA-745039.pdf6 pages
Itemised statement totalling $694.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
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.