CLM-2026-011395
Summit Cardiovascular Associates, Cardiology. Service 2026-07-09 at outpatient hospital (POS 22). Received 2026-07-29.
Member
Resolved through the identity graph
- Member
- Virginia Watkins
- Member ID
- UHC-85208-07
- Date of birth
- 1948-06-01
- Identity
- Verified3 records, confidence 1.00
- Claim record
- CLMCLM-416541
- Relationship
- Self, Scottsdale, AZ
Coverage and accumulators
Found by member ID
- Plan
- MEDICARE-ADV-B MA group GRP-2499
- Coverage period
- 2021-06-01 to present
- Deductible
- $474.71 of $2,500.0019%
- Out-of-pocket maximum
- $3,337.19 of $7,500.0044%
- Copays
- office $30.00, specialist $50.00, emergency $150.00
- Physical therapy visits
- 8 of 20 used
Provider
Billing and rendering
- Billing provider
- Summit Cardiovascular AssociatesCardiology · taxonomy 207RC0000X
- NPI
- 5138686964
- Network
- In network
- Rendering NPI
- 5858555811
- Location
- Houston, TX · TIN 53-6389420
- 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 | 93306 rev 0480 | Echocardiogram, complete | — | 1 | 1 | $1,185.00 | $651.75 | $651.75 | $0.00 | Paid |
| Totals | $1,185.00 | $651.75 | $651.75 | $0.00 | ||||||
- 1. I25.10 Atherosclerotic heart disease of native coronary artery without anginaprincipal
- 2. I50.9 Heart failure, unspecified
- Patient account
- PA-420162
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-22 12:44
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-005476 (verified, link confidence 1.00). | |
| Eligibility | Pass | Active on 2026-07-09: MEDICARE-ADV-B (MA), effective 2021-06-01. | |
| Timely filing | Pass | Received 20 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 Summit Cardiovascular Associates (5138686964). | |
| 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: Summit Cardiovascular Associates2026-07-09 16:34
Patient seen for atherosclerotic heart disease of native coronary artery without angina.
Attachments
Documents received with the claim
- Itemized billitemized_PA-420162.pdf7 pages
Itemised statement totalling $1185.00 across 1 line.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-22 12:44Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-004563 | 2026-04-08 | Unity Medical Group | $427.00 | Needs review |
AI recommendation
assist mode · apac.amazon.nova-pro-v1:0
Examiner decision
Approved by Claims rules engine; an examiner may still override
Evaluation truth
Hidden label from the synthetic generator; never shown to the model
Clean claim, priced at contract rate.