CLM-2026-009839
Desert Heart Institute, Cardiology. Service 2025-12-30 at outpatient hospital (POS 22). Received 2026-01-14.
Member
Resolved through the identity graph
- Member
- Michael Flores
- Member ID
- UHC-18243-61
- Date of birth
- 2000-05-13
- Identity
- Verified6 records, confidence 0.99
- Claim record
- CLMCLM-417329
- Relationship
- Self, Las Vegas, NV
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-6936
- Coverage period
- 2021-09-01 to 2026-06-18
- Deductible
- $294.49 of $500.0059%
- Out-of-pocket maximum
- $213.98 of $1,500.0014%
- Copays
- office $30.00, specialist $40.00, emergency $250.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Desert Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5901282678
- Network
- In network
- Rendering NPI
- 9604618642
- Location
- Mesa, AZ · TIN 39-5178200
- Authorisation / referral
- PHONE-550073 / 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 | $6,810.00 | $3,745.50 | — | — | Review |
| Totals | $6,810.00 | $3,745.50 | — | — | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- Patient account
- PA-525922
- 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-004183 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2025-12-30: MEDICARE-ADV-A (MA), effective 2021-09-01, terms 2026-06-18. | |
| Timely filing | Pass | Received 15 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Review | CO197 | Authorisation reference “PHONE-550073” does not match the utilisation-management format; must be confirmed before payment. Precertification or authorization absent |
| Provider network | Pass | In-network provider Desert Heart Institute (5901282678). | |
| 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: Desert Heart Institute2025-12-30 09:53
Patient seen for atherosclerotic heart disease of native coronary artery without angina. Authorisation was obtained by phone from the plan on the day before service; reference number recorded on the face sheet.
- SystemSystem: Claims system2026-01-14 01:36
Authorisation number on the claim does not match the UM system format. Provider states it was issued by phone.
- AdministrativeExaminer: L. Brooks (Nurse Reviewer, RN)2026-01-14 08:11
Called the provider office; awaiting documentation.
Attachments
Documents received with the claim
- Prior auth letterface_sheet_PA-525922.pdf1 page
Provider face sheet with a handwritten authorisation reference; no plan letterhead.
- Itemized billitemized_PA-525922.pdf8 pages
Itemised statement totalling $6810.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Prior authorisation: Authorisation reference “PHONE-550073” does not match the utilisation-management format; must be confirmed before payment.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-033031 | 2026-03-13 | Meadow Primary Care Associates | $191.00 | Approved |
| CLM-2026-023454 | 2026-02-13 | Harbor Diabetes Center | $394.00 | Needs review |
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
Authorisation must be confirmed with UM before payment.