CLM-2026-011654
Northgate Heart Institute, Cardiology. Service 2026-07-16 at outpatient hospital (POS 22). Received 2026-08-14.
Member
Resolved through the identity graph
- Member
- Andrea Carroll
- Member ID
- UHC-45950-02
- Date of birth
- 1988-07-02
- Identity
- Verified4 records, confidence 0.99
- Claim record
- CLMCLM-408959
- Relationship
- Self, Sacramento, CA
Coverage and accumulators
Found by member ID
- Plan
- CORE-HMO HMO group GRP-8898
- Coverage period
- 2023-02-01 to present
- Deductible
- $199.58 of $1,500.0013%
- Out-of-pocket maximum
- $2,515.63 of $6,000.0042%
- Copays
- office $25.00, specialist $75.00, emergency $150.00
- Physical therapy visits
- 5 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 5192135197
- Network
- In network
- Rendering NPI
- 7416020890
- Location
- San Diego, CA · TIN 46-7688844
- Authorisation / referral
- PA2025409717 / 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 | $1,079.00 | $593.45 | $593.45 | $0.00 | Paid |
| 2 | 93458 rev 0481 | Cardiac catheterisation, left heart | — | 1 | 1 | $5,352.00 | $2,943.60 | $1,377.96 | $1,565.64 | Paid |
| Totals | $6,431.00 | $3,537.05 | $1,971.41 | $1,565.64 | ||||||
- 1. I10 Essential (primary) hypertensionprincipal
- Patient account
- PA-562970
- Frequency code
- 1 (original)
- Accident
- No
- DRG
- —
- Admit / discharge
- —
- Landed
- 2026-10-21 13:43
Rules engine
CLAIMS-ADJ v1: 11 checks, 0 needing attention
| Check | Result | Code | Detail |
|---|---|---|---|
| Member identity | Pass | Attached to MBR-024646 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-07-16: CORE-HMO (HMO), effective 2023-02-01. | |
| Timely filing | Pass | Received 29 days after service (limit 90). | |
| Duplicate check | Pass | No matching prior claim in the duplicate window. | |
| Prior authorisation | Pass | Authorisation PA2025409717 on file for 93458. | |
| Provider network | Pass | In-network provider Northgate Heart Institute (5192135197). | |
| 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: Northgate Heart Institute2026-07-16 11:37
Patient seen for essential (primary) hypertension.
Attachments
Documents received with the claim
- Prior auth letterPA2025409717_approval.pdf2 pages
Utilisation management approval letter for 93306 (Echocardiogram, complete), valid 2026-07-16 to 2026-10-14.
- Itemized billitemized_PA-562970.pdf2 pages
Itemised statement totalling $6431.00 across 2 lines.
Explanation of benefits
What the member will see
Claim history
Every event on this claim, sealed in the audit chain
- Rules engineApproved2026-10-21 13:43Clean claim.
Other claims for this member
Same resolved identity
| Claim | Service | Provider | Billed | Status |
|---|---|---|---|---|
| CLM-2026-020898 | 2026-10-02 | Pinecrest Behavioral Health | $557.00 | Approved |
| CLM-2026-011655 | 2026-07-16 | Northgate Heart Institute | $6,431.00 | Needs review |
| CLM-2026-000788 | 2026-02-22 | Cornerstone Reference Lab | $155.00 | Denied |
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.