CLM-2026-011091
Riverside Cardiovascular Associates, Cardiology. Service 2026-01-16 at outpatient hospital (POS 22). Received 2026-02-10.
Member
Resolved through the identity graph
- Member
- Carol Kelly
- Member ID
- UHC-09522-48
- Date of birth
- 1939-10-17
- Identity
- Verified5 records, confidence 0.99
- Claim record
- CLMCLM-418345
- Relationship
- Spouse, Seattle, WA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-1837
- Coverage period
- 2025-11-01 to present
- Deductible
- $1,010.78 of $1,500.0067%
- Out-of-pocket maximum
- $1,392.24 of $3,000.0046%
- Copays
- office $20.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 11 of 20 used
Provider
Billing and rendering
- Billing provider
- Riverside Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 4236552608
- Network
- In network
- Rendering NPI
- 4868545300
- Location
- Atlanta, GA · TIN 37-2658699
- Authorisation / referral
- PA2026494769 / REF444333
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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,465.00 | $805.75 | — | — | Review |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $7,070.00 | $3,888.50 | — | — | Review |
| Totals | $8,535.00 | $4,694.25 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- Patient account
- PA-755418
- 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-011970 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-01-16: CORE-HMO (HMO), effective 2025-11-01. | |
| Timely filing | Pass | Received 25 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2026494769 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 | Review | CO16 | Documentation incomplete: “Established patient presents with unspecified atrial fibrillation; symptoms reviewed and v”. 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: Riverside Cardiovascular Associates2026-01-16 15:29
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-02-10 00:36
Rendering provider signature missing on the attached note. Development letter sent to provider.
Attachments
Documents received with the claim
- Prior auth letterPA2026494769_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-01-16 to 2026-04-16.
- Itemized billitemized_PA-755418.pdf9 pages
Itemised statement totalling $8535.00 across 2 lines.
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineReview2026-10-21 13:43Completeness: Documentation incomplete: “Established patient presents with unspecified atrial fibrillation; symptoms reviewed and v”.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-014769 | 2026-07-11 | Northgate Internal Medicine Associates | $65.00 | Approved |
| CLM-2026-021133 | 2026-02-10 | Mesa Physical Therapy | $531.00 | 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
Development letter outstanding.