CLM-2026-009827
Riverside Cardiovascular Associates, Cardiology. Service 2026-01-08 at outpatient hospital (POS 22). Received 2026-01-28.
Member
Resolved through the identity graph
- Member
- Alexander Estrada
- Member ID
- UHC-81386-36
- Date of birth
- 2004-12-02
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-426877
- Relationship
- Self, Houston, TX
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-9052
- Coverage period
- 2022-07-01 to present
- Deductible
- $1,085.81 of $1,500.0072%
- Out-of-pocket maximum
- $268.07 of $3,000.009%
- Copays
- office $40.00, specialist $60.00, emergency $350.00
- Physical therapy visits
- 20 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 9526823247
- Location
- Atlanta, GA · TIN 37-2658699
- Authorisation / referral
- PA2026737672 / 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 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,049.00 | $2,776.95 | — | — | Review |
| Totals | $5,049.00 | $2,776.95 | — | — | ||||||
- 1. R07.9 Chest pain, unspecifiedprincipal
- Patient account
- PA-957073
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- 287
- 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-003049 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-01-08: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 20 days after service (limit 90). | |
| Duplicate check | Review | DUP | Same member, date of service and procedures as CLM-2026-009826, billed by a different provider. Possible duplicate |
| Prior authorisation | Pass | Authorisation PA2026737672 on file for 93458. | |
| 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 Associates2026-01-08 11:44
Follow-up for chest pain, unspecified. Plan discussed, medications reconciled. Patient was seen earlier the same day by another provider for an unrelated complaint.
- SystemSystem: Claims system2026-01-28 00:50
Edit 018 fired on a different billing provider for the same date of service. Needs review before release.
Attachments
Documents received with the claim
- Prior auth letterPA2026737672_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-01-08 to 2026-04-08.
- Itemized billitemized_PA-957073.pdf5 pages
Itemised statement totalling $5049.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Duplicate check: Same member, date of service and procedures as CLM-2026-009826, billed by a different provider.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-009826 | 2026-01-08 | Summit Heart Institute | $5,049.00 | Approved |
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
Different billing provider; separately payable.