CLM-2026-010467
Harbor Cardiovascular Associates, Cardiology. Service 2026-02-15 at outpatient hospital (POS 22). Received 2026-03-27.
Member
Resolved through the identity graph
- Member
- Matthew Bradley
- Member ID
- UHC-67838-83
- Date of birth
- 1974-06-22
- Identity
- Verified3 records, confidence 0.98
- Claim record
- CLMCLM-423386
- Relationship
- Spouse, Glendale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-A MA group GRP-3843
- Coverage period
- 2022-07-01 to present
- Deductible
- $894.13 of $1,000.0089%
- Out-of-pocket maximum
- $1,457.34 of $4,000.0036%
- Copays
- office $25.00, specialist $40.00, emergency $350.00
- Physical therapy visits
- 22 of 20 used
Provider
Billing and rendering
- Billing provider
- Harbor Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 1432011819
- Network
- In network
- Rendering NPI
- 6473882697
- Location
- Nashville, TN · TIN 57-5710121
- 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 | $524.00 | $288.20 | — | — | Review |
| Totals | $524.00 | $288.20 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-745723
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 1 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-022353 (verified, link confidence 0.98). | |
| Eligibility | Pass | Active on 2026-02-15: MEDICARE-ADV-A (MA), effective 2022-07-01. | |
| Timely filing | Pass | Received 40 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 Harbor Cardiovascular Associates (1432011819). | |
| Medical necessity | Pass | Diagnosis supports the procedures billed. | |
| Bundling (NCCI) | Pass | No bundling conflicts. | |
| Benefit limits | Pass | No limited benefit on this claim. | |
| Completeness | Review | CO16 | Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”. Claim lacks information needed for adjudication |
| High-dollar review | Pass | Within the auto-adjudication ceiling. |
Notes
Provider, system and examiner notes on this claim
- ClinicalProvider: Harbor Cardiovascular Associates2026-02-15 14:06
Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.
- SystemSystem: Claims system2026-03-27 03:50
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Itemized billitemized_PA-745723.pdf6 pages
Itemised statement totalling $524.00 across 1 line.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-22 12:44Completeness: Documentation incomplete: “Patient seen for unspecified atrial fibrillation. Note dictated; signature pending.”.
Other claims for this member
Same resolved identity
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
Development letter outstanding.