Claims workbench/CLM-2026-011307

Institutional claim · UB-04 · EDI 837I

CLM-2026-011307

Unity Cardiovascular Associates, Cardiology. Service 2026-05-22 at outpatient hospital (POS 22). Received 2026-07-03.

DeniedIdentity on hold: CASE-002385

Billed

$10,634.00

2 lines

Allowed

$5,848.70

if approved

Plan pays

—

Denied

Member owes

—

copay / deductible / 10% coinsurance

Rules engine

Deny

CO27

Decided by

Claims rules engine

2026-10-21 13:43

Member

Resolved through the identity graph

Member: Justin Walker
Member ID: UHC-88686-62
Date of birth: 1991-05-28
Identity: Provisional1 records, confidence 1.00
Claim record: CLMCLM-412992
Relationship: Self, Minneapolis, MN

Coverage and accumulators

Found by member ID

Plan: MEDICARE-ADV-A MA group GRP-2270
Coverage period: 2023-12-01 to 2026-04-28
Deductible: $2,897.97 of $3,500.0083%
Out-of-pocket maximum: $447.29 of $10,500.004%
Copays: office $40.00, specialist $60.00, emergency $350.00
Physical therapy visits: 22 of 20 used

Provider

Billing and rendering

Billing provider: Unity Cardiovascular Associates
Cardiology · taxonomy 207RC0000X
NPI: 2734278403
Network: In network
Rendering NPI: 2895838797
Location: Atlanta, GA · TIN 78-7453975
Authorisation / referral: PA2025988838 / 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	$9,359.00	$5,147.45	—	—	DeniedCO27
2	93306 rev 0480	Echocardiogram, complete	—	1	1	$1,275.00	$701.25	—	—	DeniedCO27
Totals						$10,634.00	$5,848.70	—	—

Diagnoses (ICD-10-CM)

1. R07.9 Chest pain, unspecifiedprincipal
2. I10 Essential (primary) hypertension

Claim header

Patient account: PA-666309
Frequency code: 1 (original)
Accident: No
DRG: 287
Admit / discharge: —
Landed: 2026-10-21 13:43

Rules engine

CLAIMS-ADJ v1: 11 checks, 2 needing attention

Check	Result	Code	Detail
Member identity	Fail	IDQ	Member record is in open steward case CASE-002385; payment withheld until the identity is confirmed. Member identity under steward review
Eligibility	Fail	CO27	Date of service 2026-05-22 is after coverage terminated on 2026-04-28. Expenses incurred after coverage terminated
Timely filing	Pass		Received 42 days after service (limit 90).
Duplicate check	Pass		No matching prior claim in the duplicate window.
Prior authorisation	Pass		Authorisation PA2025988838 on file for 93458.
Provider network	Pass		In-network provider Unity Cardiovascular Associates (2734278403).
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.

Evaluated 2026-10-21 13:43 under policy version 1. Hard rule fired: Denied.

Notes

Provider, system and examiner notes on this claim

ClinicalProvider: Unity Cardiovascular Associates2026-05-22 11:07
Established patient presents with chest pain, unspecified; symptoms reviewed and vitals within expected range.
SystemSystem: Claims system2026-07-03 02:26
AdministrativeExaminer: M. Alvarez (Claims Examiner I)2026-07-03 14:57
Escalated to nurse reviewer for clinical opinion.

Attachments

Documents received with the claim

Prior auth letterPA2025988838_approval.pdf2 pages
Utilisation management approval letter for 93458 (Cardiac catheterisation, left heart), valid 2026-05-22 to 2026-08-20.
Itemized billitemized_PA-666309.pdf3 pages
Itemised statement totalling $10634.00 across 2 lines.

Claim history

Every event on this claim, sealed in the audit chain

Rules engineDenied2026-10-21 13:43
Member identity: Member record is in open steward case CASE-002385; payment withheld until the identity is confirmed. Eligibility: Date of service 2026-05-22 is after coverage terminated on 2026-04-28.

Other claims for this member

Same resolved identity

No other claims.

AI recommendation

assist mode · apac.amazon.nova-pro-v1:0

A hard rule decided this claim; the AI is advisory here.

Examiner decision

Denied by Claims rules engine; an examiner may still override

Outcome

Approve and pay as pricedAllowed amount, member responsibility and plan payment are applied to every line.DenyNo payment. Reason codes go on the remittance advice and the member's explanation of benefits.Pend for informationHold the claim; a development letter or confirmation is needed before it can be finalised.Refer to special investigationsRoute to the SIU for a fraud, waste and abuse review. No payment until cleared.

Examiner rationale *

At least 8 characters (0/8)

ExaminerR. Patel (Claims Examiner II)

Choose an outcome

Evaluation truth

Hidden label from the synthetic generator; never shown to the model

DeniedCO27scenario: Coverage terminated

Service after coverage termination.

Review queue Member identity