CLM-2026-012268
Northgate Heart Institute, Cardiology. Service 2026-09-06 at office (POS 11). Received 2026-09-23.
Member
Resolved through the identity graph
- Member
- Lawrence Nichhols
- Member ID
- UHC-93718-40
- Date of birth
- 1979-03-14
- Identity
- Verified2 records, confidence 0.99
- Claim record
- CLMCLM-420325
- Relationship
- Self, Atlanta, GA
Coverage and accumulators
Found by member ID
- Plan
- OPTIONS-PPO PPO group GRP-5923
- Coverage period
- 2021-12-01 to present
- Deductible
- $854.55 of $1,000.0085%
- Out-of-pocket maximum
- $891.00 of $4,000.0022%
- Copays
- office $25.00, specialist $50.00, emergency $350.00
- Physical therapy visits
- 4 of 20 used
Provider
Billing and rendering
- Billing provider
- Northgate Heart InstituteCardiology · taxonomy 207RC0000X
- NPI
- 1929886434
- Network
- In network
- Rendering NPI
- 2418714657
- Location
- Los Angeles, CA · TIN 48-8536899
- Authorisation / referral
- none / none
Service lines
CMS-1500: procedures, modifiers, units, charges and the pricing outcome per line
| Line | Code | Description | Mod. | Units | Dx | Billed | Allowed | Member | Plan | Line status |
|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 93224 | Holter monitor, 48 hours | — | 1 | 1 | $333.00 | $206.46 | — | — | Review |
| 2 | 99214 | Office visit, established patient, moderate complexity | 25 | 1 | 2 | $256.00 | $158.72 | — | — | Review |
| Totals | $589.00 | $365.18 | — | — | ||||||
- 1. I48.91 Unspecified atrial fibrillationprincipal
- 2. R07.9 Chest pain, unspecified
- Patient account
- PA-827102
- 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-025679 (verified, link confidence 0.99). | |
| Eligibility | Pass | Active on 2026-09-06: OPTIONS-PPO (PPO), effective 2021-12-01. | |
| Timely filing | Pass | Received 17 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 Northgate Heart Institute (1929886434). | |
| 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: Northgate Heart Institute2026-09-06 18:52
Established patient presents with unspecified atrial fibrillation; symptoms reviewed and vitals within expected range. Note dictated; signature pending.
- SystemSystem: Claims system2026-09-23 00:15
Rendering provider signature missing on the attached note. Development letter sent to provider.
- AdministrativeExaminer: T. Nguyen (Senior Claims Examiner)2026-09-23 14:48
Escalated to nurse reviewer for clinical opinion.
Attachments
Documents received with the claim
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
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.